Use of dianhydrogalactitol and analogs and derivatives thereof to treat glioblastoma multiforme

ABSTRACT

The use of dianhydrogalactitol provides a novel therapeutic modality for the treatment of glioblastoma multiforme. Dianhydrogalactitol acts as an alkylating agent on DNA that creates N 7  methylation. Dianhydrogalactitol is effective in suppressing the growth of cancer stem cells and is active against tumors that are refractory to temozolomide; the drug acts independently of the MGMT repair mechanism.

CROSS-REFERENCES

This application is a continuation-in-part of PCT Patent ApplicationSerial No. PCT/US2013/022505 by J. Bacha et al., filed on Jan. 22, 2013and entitled “Use of Dianhydrogalactitol to Treat GlioblastomaMultiforme and Medulloblastoma,” which in turn claimed the benefit ofU.S. Provisional Application Ser. No. 61/589,029 by J. Bacha et al.,filed on Jan. 20, 2012, and entitled “Use of Dianhydrogalactitol toTreat Glioblastoma Multiforme and Medulloblastoma,” the contents ofwhich are incorporated herein in their entirety by this reference.

FIELD OF THE INVENTION

This application is directed to the use of dianhydrogalactitol (DAG) andanalogs and derivatives thereof to treat glioblastoma multiforme (GBM),as well as pharmaceutical compositions suitable for such use.

BACKGROUND OF THE INVENTION

Glioblastoma multiforme (GBM) is the most common and aggressivemalignant primary brain tumor occurring in humans. GBM involves glialcells; it accounts for 52% of all functional tissue brain tumor casesand 20% of all intracranial tumors. Its estimated frequency ofoccurrence is 2-3 cases per 100,000 people in Europe and North America.

GBM has an extremely poor prognosis, despite various treatment methodsincluding open craniotomy with surgical resection of as much of thetumor as possible, followed by sequential or concurrentchemoradiotherapy, antiangiogenic therapy with bevacizumab, gamma kniferadiosurgery, and symptomatic management with corticosteroids. Themedian survival time for GBM is only 14 months.

Common symptoms of GBM include seizures, nausea, vomiting, headache, andhemiparesis. However, the single most prevalent symptom of GBM isprogressive memory, personality, or neurological deficit due toinvolvement of the temporal or frontal lobe of the brain. The kind ofsymptoms produced by GBM depends highly on the location of the tumor andless on its exact pathology. The tumor can start producing symptomsquickly, but occasionally is asymptomatic until it reaches an extremelylarge size.

The etiology of GBM is largely unknown. For unknown reasons, GBM occursmore frequently in males. Most glioblastoma tumors appear to besporadic, without any significant genetic predisposition. No links havebeen found between GBM, and several known carcinogenic risk factors,including diet, smoking, and exposure to electromagnetic fields. Therehave been some suggestions of a viral etiology, possibly SV40 orcytomegalovirus. There may also be some association between exposure toionizing radiation and GBM. Additionally, it has been proposed thatthere is a link between polyvinyl chloride exposure and GBM; leadexposure in the workplace has also been suggested as a possible cause.There is an association of brain tumor incidence and malaria, suggestingthat the anopheles mosquito, the carrier of malaria, might transmit avirus or other causative agent of GBM.

GBM is also relatively more common in people over 50 years of age, inCaucasians or Asians, and in patients that have already developed alow-grade astrocytoma which can develop into a higher grade tumor.Additionally, having one of the following genetic disorders isassociated with an increased incidence of GBM: neurofibromatosis,tuberous sclerosis, Von Hippel-Lindau disease, Li-Fraumeni syndrome, orTurcot syndrome.

GBM tumors are typically characterized by the presence of small areas ofnecrotizing tissue that are surrounded by anaplastic cells. Thesecharacteristics, together with the presence of hyperplastic bloodvessels, differentiate these malignancies from Grade 3 astrocytomas,which do not have these features.

There are four subtypes of glioblastoma. An extremely large fraction(97%) of tumors in the so-called “classical” subtype carry extra copiesof the epidermal growth factor receptor (EGFR) gene and most of thesetumors have higher than normal expression of EGFR, whereas the geneTP53, a tumor suppressor gene that has a number of anticanceractivities, and which is often mutated in glioblastoma, is rarelymutated in this subtype. In contrast, the proneural subtype often hashigh rates of alteration in TP53 and in PDGFRA, the gene encoding theα-type platelet-derived growth factor receptor, as well as in IDH1, thegene encoding isocitrate dehydrogenase-1. The mesenchymal subtype ischaracterized by high rates of mutations or alterations in NF1, the geneencoding Neurofibromin type 1 and fewer alterations in the EGFR gene andless expression of EGFR than the other subtypes.

GBM usually forms in the cerebral white matter, grows quickly, and canbecome very large before producing symptoms. Less than 10% of GBMs formmore slowly following degeneration of low-grade astrocytoma oranaplastic astrocytoma; such tumors are called secondary GBMs and arerelatively more common in younger patients. The tumor may extend intothe meninges or the ventricular wall leading to abnormally high proteincontent in the cerebrospinal fluid (CSF) (>100 mg/dL), as well as anoccasional pleocytosis of 10 to 100 cells, mostly lymphocytes. Malignantcells present in the CSF can rarely spread to the spinal cord or causemeningeal gliomatosis; however, metastasis of GBM beyond the centralnervous system is extremely unusual. About 50% of GBM tumors occupy morethan one lobe of a hemisphere or are bilateral. Tumors of this typeusually arise from the cerebrum and may rarely exhibit the classicinfiltration across the corpus callosum, producing a bilateral(“butterfly”) glioma. The tumor can take on a variety of appearances,depending on the amount of hemorrhage or necrosis present or the age ofthe tumor. A CT scan of a GBM tumor will usually show an inhomogeneousmass with a hypodense center and a variable ring of enhancementsurrounded by edema. The mass effect from the tumor and the surroundingedema may compress the ventricles and cause hydrocephalus.

Cancer cells with stem-cell-like properties have been found inglioblastomas. This may be one cause of their resistance to conventionaltreatments and their high recurrence rate.

GBM often presents typical features on MRI, but these features are notspecific for GBM and may be caused by other conditions. Specifically,when viewed with MRI, GBMs often appear as ring-enhancing lesions.However, other lesions such as abscesses, metastases of malignanciesarising outside the central nervous system, tumefactive multiplesclerosis, or other conditions may have a similar appearance. Thedefinitive diagnosis of a suspected GBM on CT or MRI requires astereotactic biopsy or a craniotomy with tumor resection and pathologicconfirmation. Because the grade of the tumor is based on the mostmalignant portion of the tumor, biopsy or subtotal tumor resection canresult in undergrading of the tumor. Imaging of tumor blood flow usingperfusion MRI and measuring tumor metabolite concentration with MRspectroscopy may add value to standard MRI, but pathology remains thegold standard for GBM diagnosis.

The treatment of GBM is extremely difficult due to several factors: (1)the tumor cells are very resistant to conventional therapies; (2) thebrain is susceptible to damage using conventional therapy; (3) the brainhas a very limited capacity for self-repair; and (4) many therapeuticdrugs cannot cross the blood-brain barrier to act on the tumor.Symptomatic therapy, including the use of corticosteroids andanticonvulsant agents, focuses on relieving symptoms and improving thepatient's neurologic function. However, such symptomatic therapy doesnothing to slow the progression of the tumor, and, in the case ofadministration of phenytoin concurrently with radiation therapy, canresult in substantial side effects including erythema multiforme andSteven-Johnson syndrome.

Palliative therapy usually is conducted to improve quality of life andto achieve a longer survival time. Palliative therapy can includesurgery, radiation therapy, and chemotherapy. A maximally feasibleresection with maximally tumor-free margins is generally performed alongwith external beam radiation and chemotherapy. Gross total resection oftumor is associated with better prognoses.

Surgery is the first stage of treatment of glioblastoma. An average GBMtumor contains 10¹¹ cells, which is on average reduced to 10⁹ cellsafter surgery (a reduction of 99%). Surgery is used to take a sectionfor a pathological diagnosis, to remove some of the symptoms of a largemass pressing against the brain, to remove disease before secondaryresistance to radiotherapy and chemotherapy, and to prolong survival.The greater the extent of tumor removal, the better is the outcome.Removal of 98% or more of the tumor has been associated with asignificantly longer and healthier survival time than if less than 98%of the tumor is removed. The chances of near-complete initial removal ofthe tumor can be greatly increased if the surgery is guided by afluorescent dye known as 5-aminolevulinic acid. GBM cells are widelyinfiltrative through the brain at diagnosis, and so despite a “totalresection” of all obvious tumor, most people with GBM later developrecurrent tumors either near the original site or at more distant“satellite lesions” within the brain. Other modalities, includingradiation, are used after surgery in an effort to suppress and slowrecurrent disease.

After surgery, radiotherapy is the mainstay of treatment for people withglioblastoma. A pivotal clinical trial carried out in the early 1970sshowed that among 303 GBM patients randomized to radiation ornonradiation therapy, those who received radiation had a median survivalmore than double those who did not. Subsequent clinical research hasattempted to build on the backbone of surgery followed by radiation. Onaverage, radiotherapy after surgery can reduce the tumor size to 10⁷cells. Whole brain radiotherapy does not improve the results whencompared to the more precise and targeted three-dimensional conformalradiotherapy. A total radiation dose of 60-65 Gy has been found to beoptimal for treatment.

The use of chemotherapy in GBM in addition to radiation has thus faronly resulted in marginal improvements in survival as compared withradiation alone. In the treatment of other malignancies, the addition ofchemotherapy to radiation has resulted in substantial improvements insurvival, but this has not yet proven to be the case for GBM. One drugthat does show results in connection with radiation is temozolomide(TMZ). TMZ plus radiation is now standard for most cases of GBM. TMZseems to work by sensitizing the tumor cells to radiation.

However, TMZ is often ineffective due to drug resistance as the resultof the catalytic activity of the enzyme O⁶-methylguanine-DNAmethyltransferase (MGMT), which results in repair of the lesion at O⁶ ofthe guanine of DNA molecules. Chemoresistance to TMZ as a result of theactivity of MGMT is frequently associated with poor outcomes inTMZ-treated patients, and patients in whom TMZ or bevacizumab isineffective are left with few if any treatment options.

Additionally, cancer stem cells (CSC) are a subpopulation of the tumorthat resist therapy and give rise to relapse.

Another therapeutic approach involves the use of the monoclonal antibodybevacizumab, which is a humanized monoclonal antibody that inhibitsvascular endothelial growth factor A (VEGF-A) and thus acts as anangiogenesis inhibitor. Although bevacizumab may retard the progressionof the disease, the first-line use of bevacizumab does not improveoverall survival in patients with newly diagnosed GBM (M. R. Gilbert etal., “A Randomized Trial of Bevacizumab for Newly DiagnosedGlioblastoma,” New Engl. J. Med. 370: 699-708 (2014), incorporatedherein by this reference). Additionally, unlike some other malignanciesin which the use of bevacizumab results in a potentiation ofchemotherapy, in GBM, the addition of chemotherapy to bevacizumab didnot improve on results from bevacizumab alone. Bevacizumab reduces brainedema and consequent symptoms, and it may be that the benefit from thisdrug is due to its action against edema rather than any action againstthe tumor itself. Some patients with brain edema do not actually haveany active tumor remaining, but rather develop the edema as a lateeffect of prior radiation treatment. This type of edema is difficult todistinguish from that due to tumor, and both may coexist. Both respondto bevacizumab. However, patients in which both temozolomide andbevacizumab have been ineffective have few if any treatment options.

Another approach that has been proposed is gene transfer. Although genetransfer therapy has the potential to kill cancer cells while leavinghealthy cells unharmed, this approach has been beset with manydifficulties in other diseases, including the possibility for inductionof other types of malignancies and interference with the functioning ofthe immune system.

Still other treatment modalities have been proposed for GBM, includingthe use of protein therapeutics, including the soluble CD95-Fc fusionprotein APG101, immunotherapy with tumor vaccines, alternatingelectrical fields, and metabolic therapy. The value of these treatmentmodalities remains to be determined.

In GBM, the median survival time from the time of diagnosis without anytreatment is 3 months, but with treatment survival of 1-2 years iscommon. Increasing age (>60 years of age) carries a worse prognosticrisk. Death is usually due to cerebral edema or increased intracranialpressure.

A good initial Karnofsky Performance Score (KPS) and methylation of thepromoter of the O⁶-methylguanine-DNA methyltransferase (MGMT) gene areassociated with longer survival. A DNA test can be carried out onglioblastomas to determine whether the promoter of the MGMT gene ismethylated. Even in patients less than 50 years of age with a KarnofskyPerformance Score (KPS) of equal to or greater than 90%, the 5-yearsurvival rate is only 14%.

Therefore, there is a need for improved therapies for glioblastomamultiforme that provide improved survival with reduced side effects andimpairment of function in surviving patients.

There is a particular need for therapeutic modalities that can cross theblood-brain barrier (BBB), that can suppress the growth and division ofcancer stem cells (CSC), and that can avoid inactivation byO⁶-methylguanine-DNA methyltransferase (MGMT). There is also aparticular need for therapeutic modalities that yield increased responserates and improved quality of life for patients with these malignancies.There is also a particular need for therapeutic modalities that areeffective in patients in which either or both of temozolomide andbevacizumab have proven ineffective.

SUMMARY OF THE INVENTION

The use of a substituted hexitol derivative to treat glioblastomamultiforme (GBM) provides an improved therapy for GBM that yieldsincreased survival and is substantially free of side effects. Ingeneral, the substituted hexitols usable in methods and compositionsaccording to the present invention include galactitols, substitutedgalacitols, dulcitols, and substituted dulcitols. Typically, thesubstituted hexitol derivative is selected from the group consisting ofdianhydrogalactitol, derivatives of dianhydrogalactitol,diacetyldianhydrogalactitol, derivatives of diacetyldianhydrogalactitol,dibromodulcitol, and derivatives of dibromodulcitol. A particularlypreferred substituted hexitol derivative is dianhydrogalactitol (DAG).The substituted hexitol derivative can be employed together with othertherapeutic modalities for these malignancies. Dianhydrogalactitol isparticularly suited for the treatment of these malignancies because itcrosses the blood-brain barrier, because it can suppress the growth ofcancer stem cells (CSC), and because it is resistant to druginactivation by O⁶-methylguanine-DNA methyltransferase (MGMT). Thesubstituted hexitol derivative yields increased response rates andimproved quality of life for patients with GBM.

Dianhydrogalactitol is a novel alkylating agent that createsN⁷-alkylation in DNA. Specifically, the principal mechanism of action isattributed to bi-functional N⁷ DNA alkylation, via actual or derivedepoxide groups, which cross-links across DNA strands at the N⁷ positionof guanine residues in DNA.

Accordingly, one aspect of the present invention is a method to improvethe efficacy and/or reduce the side effects of the administration of asubstituted hexitol derivative for treatment of GBM comprising the stepsof:

(1) identifying at least one factor or parameter associated with theefficacy and/or occurrence of side effects of the administration of thesubstituted hexitol derivative for treatment of GBM; and

(2) modifying the factor or parameter to improve the efficacy and/orreduce the side effects of the administration of the substituted hexitolderivative for treatment of GBM.

Typically, the factor or parameter is selected from the group consistingof:

(1) dose modification;

(2) route of administration;

(3) schedule of administration;

(4) indications for use;

(5) selection of disease stage;

(6) other indications;

(7) patient selection;

(8) patient/disease phenotype;

(9) patient/disease genotype;

(10) pre/post-treatment preparation

(11) toxicity management;

(12) pharmacokinetic/pharmacodynamic monitoring;

(13) drug combinations;

(14) chemosensitization;

(15) chemopotentiation;

(16) post-treatment patient management;

(17) alternative medicine/therapeutic support;

(18) bulk drug product improvements;

(19) diluent systems;

(20) solvent systems;

(21) excipients;

(22) dosage forms;

(23) dosage kits and packaging;

(24) drug delivery systems;

(25) drug conjugate forms;

(26) compound analogs;

(27) prodrugs;

(28) multiple drug systems;

(29) biotherapeutic enhancement;

(30) biotherapeutic resistance modulation;

(31) radiation therapy enhancement;

(32) novel mechanisms of action;

(33) selective target cell population therapeutics;

(34) use with ionizing radiation;

(35) use with an agent that counteracts myelosuppression; and

(36) use with an agent that increases the ability of the substitutedhexitol to pass through the blood-brain barrier.

As detailed above, typically, the substituted hexitol derivative isselected from the group consisting of dianhydrogalactitol, derivativesof dianhydrogalactitol, diacetyldianhydrogalactitol, derivatives ofdiacetyldianhydrogalactitol, dibromodulcitol, and derivatives ofdibromodulcitol. Preferably, the substituted hexitol derivative isdianhydrogalactitol.

Another aspect of the present invention is a composition to improve theefficacy and/or reduce the side effects of suboptimally administereddrug therapy employing a substituted hexitol derivative for thetreatment of GBM comprising an alternative selected from the groupconsisting of:

(i) a therapeutically effective quantity of a modified substitutedhexitol derivative or a derivative, analog, or prodrug of a substitutedhexitol derivative or a modified substituted hexitol derivative, whereinthe modified substituted hexitol derivative or the derivative, analog orprodrug of the substituted hexitol derivative or modified substitutedhexitol derivative possesses increased therapeutic efficacy or reducedside effects for treatment of GBM as compared with an unmodifiedsubstituted hexitol derivative;

(ii) a composition comprising:

-   -   (a) a therapeutically effective quantity of a substituted        hexitol derivative, a modified substituted hexitol derivative,        or a derivative, analog, or prodrug of a substituted hexitol        derivative or a modified substituted hexitol derivative; and    -   (b) at least one additional therapeutic agent, therapeutic agent        subject to chemosensitization, therapeutic agent subject to        chemopotentiation, diluent, excipient, solvent system, drug        delivery system, agent to counteract myelosuppression, or agent        that increases the ability of the substituted hexitol to pass        through the blood-brain barrier, wherein the composition        possesses increased therapeutic efficacy or reduced side effects        for treatment of GBM as compared with an unmodified substituted        hexitol derivative;

(iii) a therapeutically effective quantity of a substituted hexitolderivative, a modified substituted hexitol derivative or a derivative,analog, or prodrug of a substituted hexitol derivative or a modifiedsubstituted hexitol derivative that is incorporated into a dosage form,wherein the substituted hexitol derivative, the modified substitutedhexitol derivative or the derivative, analog, or prodrug of asubstituted hexitol derivative or a modified substituted hexitolderivative incorporated into the dosage form possesses increasedtherapeutic efficacy or reduced side effects for treatment of GBM ascompared with an unmodified substituted hexitol derivative;

(iv) a therapeutically effective quantity of a substituted hexitolderivative, a modified substituted hexitol derivative or a derivative,analog, or prodrug of a substituted hexitol derivative or a modifiedsubstituted hexitol derivative that is incorporated into a dosage kitand packaging, wherein the substituted hexitol derivative, the modifiedsubstituted hexitol derivative or the derivative, analog, or prodrug ofa substituted hexitol derivative or a modified substituted hexitolderivative incorporated into the dosage kit and packaging possessesincreased therapeutic efficacy or reduced side effects for treatment ofGBM as compared with an unmodified substituted hexitol derivative; and

(v) a therapeutically effective quantity of a substituted hexitolderivative, a modified substituted hexitol derivative or a derivative,analog, or prodrug of a substituted hexitol derivative or a modifiedsubstituted hexitol derivative that is subjected to a bulk drug productimprovement, wherein substituted hexitol derivative, a modifiedsubstituted hexitol derivative or a derivative, analog, or prodrug of asubstituted hexitol derivative or a modified substituted hexitolderivative subjected to the bulk drug product improvement possessesincreased therapeutic efficacy or reduced side effects for treatment ofGBM as compared with an unmodified substituted hexitol derivative.

As detailed above, typically the unmodified substituted hexitolderivative is selected from the group consisting of dianhydrogalactitol,derivatives of dianhydrogalactitol, diacetyldianhydrogalactitol,derivatives of diacetyldianhydrogalactitol, dibromodulcitol, andderivatives of dibromodulcitol. Preferably, the unmodified substitutedhexitol derivative is dianhydrogalactitol.

Another aspect of the present invention is a method of treatingglioblastoma multiforme comprising the step of administering atherapeutically effective quantity of a substituted hexitol derivativeto a patient suffering from the malignancy. As detailed above, thesubstituted hexitol derivative is selected from the group consisting ofdianhydrogalactitol, derivatives of dianhydrogalactitol,diacetyldianhydrogalactitol, derivatives of diacetyldianhydrogalactitol,dibromodulcitol, and derivatives of dibromodulcitol. Preferably, thesubstituted hexitol derivative is dianhydrogalactitol.

Typically, when the substituted hexitol derivative isdianhydrogalactitol, the therapeutically effective quantity ofdianhydrogalactitol is a dosage from about 1 mg/m² to about 40 mg/m².Preferably, the therapeutically effective quantity ofdianhydrogalactitol is a dosage from about 5 mg/m² to about 25 mg/m².Other dosages are described below.

Typically, the substituted hexitol derivative, such asdianhydrogalactitol, is administered by a route selected from the groupconsisting of intravenous and oral. Other potential routes ofadministration are described below.

The method can further comprise the step of administering atherapeutically effective dose of ionizing radiation. The method canfurther comprise the step of administering a therapeutically effectivequantity of temozolomide, bevacizumab, or a corticosteroid.

The method can further comprise the administration of a therapeuticallyeffective quantity of a tyrosine kinase inhibitor as described below.

The method can further comprise the administration of a therapeuticallyeffective quantity of an epidermal growth factor receptor (EGFR)inhibitor as described below. The EGFR inhibitor can affect eitherwild-type binding sites or mutated binding sites, including Variant III,as described below.

BRIEF DESCRIPTION OF THE DRAWINGS

The following invention will become better understood with reference tothe specification, appended claims, and accompanying drawings, where:

FIG. 1 is a chart showing three GBM cell lines used and showing theirdegree of temozolomide (TMZ) resistance and the status of methylation ofthe promoter of the O-6-methylguanine-DNA methyltransferase (MGMT) gene.

FIG. 2A is a graph showing the inhibition of growth of the GBM cell lineSF188 with increasing concentrations of TMZ and dianhydrogalactitol(DAG) (shown as “VAL” in the figures) (two experiments each). In FIG.2A, (♦) represents TMZ results and (▪) represents DAG results.

FIG. 2B is a graph showing the inhibition of growth of the GBM cell lineU251 with increasing concentrations of TMZ and DAG (two experimentseach). In FIG. 2B, (♦) represents TMZ results and (▪) represents DAGresults.

FIG. 2C is a graph showing the inhibition of growth of the GBM cell lineT98G with increasing concentrations of TMZ and DAG (two experimentseach). In FIG. 2C, (♦) represents TMZ results and (▪) represents DAGresults.

FIG. 3 is a chart showing the three cell lines used in FIGS. 2A, 2B, and2C, indicating TMZ resistance and MGMT status.

FIG. 4 is a photograph showing that DAG at 5 μM inhibits colonyformation by the GBM cell line SF188 by more than 95% after 7 days.

FIG. 5 is a graph showing that DAG inhibits the growth of SF188 cellsmore effectively than TMZ, particularly in secondary sphere formation.

FIG. 6 shows that DAG completely inhibits secondary neurosphereformation by BT74 cancer stem cells and substantially inhibits primaryneurosphere formation; photomicrographs are shown at the top, and graphsshowing the extent of inhibition are shown under the photomicrographs.

FIG. 7 is a graph showing that DAG is more efficient at inhibitingprimary neurosphere formation than TMZ for SF188 and DAOY cell lines.DAOY is a medulloblastoma cell line.

FIG. 8 is a photograph showing that DAG at 5 μM completely inhibitscolony formation by the medulloblastoma cell line DAOY after 7 days.

FIG. 9 is a graph and comparative photomicrographs showing that BT74cells do not show significant sensitivity to TMZ.

FIG. 10 is a graph showing the effect of DAG on primary adult GBM cellsisolated fresh from BCCH, showing a substantial degree of inhibition;TMZ essentially has no effect on these cells.

FIG. 11 is a set of graphs showing effect of combination treatments withTMZ and DAG on SF188 cells, showing inhibition of neurosphere formation;the combination of TMZ plus DAG provided the greatest degree ofinhibition.

FIG. 12 is a set of graphs showing effect of combination treatments withTMZ and DAG on SF188 cells, showing inhibition of colony formation; thecombination of TMZ plus DAG provided the greatest degree of inhibition.

DETAILED DESCRIPTION OF THE INVENTION

The compound dianhydrogalactitol (DAG) has been shown to havesubstantial efficacy in inhibiting the growth of glioblastoma multiforme(GBM) cells. In the case of GBM, DAG has proven to be more effective insuppressing the growth of GBM cells than temozolomide (TMZ), the currentchemotherapy of choice for GBM. As detailed below, DAG can effectivelycross the blood-brain barrier and can effectively suppress the growth ofcancer stem cells (CSCs). DAG acts independently of the MGMT repairmechanism.

The structure of dianhydrogalactitol (DAG) is shown in Formula (I),below.

As detailed below, other substituted hexitols can be used in methods andcompositions according to the present invention. In general, thesubstituted hexitols usable in methods and compositions according to thepresent invention include galactitols, substituted galacitols,dulcitols, and substituted dulcitols, including dianhydrogalactitol,diacetyldianhydrogalactitol, dibromodulcitol, and derivatives andanalogs thereof. Typically, the substituted hexitol derivative isselected from the group consisting of dianhydrogalactitol, derivativesof dianhydrogalactitol, diacetyldianhydrogalactitol, derivatives ofdiacetyldianhydrogalactitol, dibromodulcitol, and derivatives ofdibromodulcitol. Preferably, the substituted hexitol derivative isdianhydrogalactitol.

These galactitols, substituted galacitols, dulcitols, and substituteddulcitols are either alkylating agents or prodrugs of alkylating agents,as discussed further below.

Also within the scope of the invention are derivatives ofdianhydrogalactitol that, for example, have one or both hydrogens of thetwo hydroxyl groups of dianhydrogalactitol replaced with lower alkyl,have one or more of the hydrogens attached to the two epoxide ringsreplaced with lower alkyl, or have the methyl groups present indianhydrogalactitol and that are attached to the same carbons that bearthe hydroxyl groups replaced with C₂-C₆ lower alkyl or substituted with,for example, halo groups by replacing a hydrogen of the methyl groupwith, for example a halo group. As used herein, the term “halo group,”without further limitation, refers to one of fluoro, chloro, bromo, oriodo. As used herein, the term “lower alkyl,” without furtherlimitation, refers to C₁-C₆ groups and includes methyl. The term “loweralkyl” can be further limited, such as “C₂-C₆ lower alkyl,” whichexcludes methyl. The term “lower alkyl”, unless further limited, refersto both straight-chain and branched alkyl groups. These groups can,optionally, be further substituted, as described below.

The structure of diacetyldianhydrogalactitol is shown in Formula (II),below.

Also within the scope of the invention are derivatives ofdiacetyldianhydrogalactitol that, for example, have one or both of themethyl groups that are part of the acetyl moieties replaced with C₂-C₆lower alkyl, have one or both of the hydrogens attached to the epoxidering replaced with lower alkyl, or have the methyl groups attached tothe same carbons that bear the acetyl groups replaced with lower alkylor substituted with, for example, halo groups by replacing a hydrogenwith, for example, a halo group.

The structure of dibromodulcitol is shown in Formula (III), below.Dibromodulcitol can be produced by the reaction of dulcitol withhydrobromic acid at elevated temperatures, followed by crystallizationof the dibromodulcitol. Some of the properties of dibromodulcitol aredescribed in N. E. Mischler et al., “Dibromoducitol,” Cancer Treat. Rev.6: 191-204 (1979), incorporated herein by this reference. In particular,dibromodulcitol, as an α,ω-dibrominated hexitol, dibromodulcitol sharesmany of the biochemical and biological properties of similar drugs suchas dibromomannitol and mannitol myleran. Activation of dibromodulcitolto the diepoxide dianhydrogalactitol occurs in vivo, anddianhydrogalactitol may represent a major active form of the drug; thismeans that dibromogalactitol has many of the properties of a prodrug.Absorption of dibromodulcitol by the oral route is rapid and fairlycomplete. Dibromodulcitol has known activity in melanoma, breastlymphoma (both Hodgkins and non-Hodgkins), colorectal cancer, acutelymphoblastic leukemia and has been shown to lower the incidence ofcentral nervous system leukemia, non-small cell lung cancer, cervicalcarcinoma, bladder carcinoma, and metastatic hemangiopericytoma.

Also within the scope of the invention are derivatives ofdibromodulcitol that, for example, have one or more hydrogens of thehydroxyl groups replaced with lower alkyl, or have one or both of thebromo groups replaced with another halo group such as chloro, fluoro, oriodo.

In general, for optional substituents at saturated carbon atoms such asthose that are part of the structures of dianhydrogalactitol,derivatives of dianhydrogalactitol, diacetyldianhydrogalactitol,derivatives of diacetyldianhydrogalactitol, dibromodulcitol, andderivatives of dibromodulcitol, the following substituents can beemployed: C₆-C₁₀ aryl, heteroaryl containing 1-4 heteroatoms selectedfrom N, O, and S, C₁-C₁₀ alkyl, C₁-C₁₀ alkoxy, cycloalkyl, F, amino(NR¹R²), nitro, —SR, —S(O)R, —S(O₂)R, —S(O₂)NR¹R², and —CONR¹R², whichcan in turn be optionally substituted. Further descriptions of potentialoptional substituents are provided below.

Optional substituents as described above that are within the scope ofthe present invention do not substantially affect the activity of thederivative or the stability of the derivative, particularly thestability of the derivative in aqueous solution. Definitions for anumber of common groups that can be used as optional substituents areprovided below; however, the omission of any group from thesedefinitions cannot be taken to mean that such a group cannot be used asan optional substituent as long as the chemical and pharmacologicalrequirements for an optional substituent are satisfied.

As used herein, the term “alkyl” refers to an unbranched, branched, orcyclic saturated hydrocarbyl residue, or a combination thereof, of from1 to 12 carbon atoms that can be optionally substituted; the alkylresidues contain only C and H when unsubstituted. Typically, theunbranched or branched saturated hydrocarbyl residue is from 1 to 6carbon atoms, which is referred to herein as “lower alkyl.” When thealkyl residue is cyclic and includes a ring, it is understood that thehydrocarbyl residue includes at least three carbon atoms, which is theminimum number to form a ring. As used herein, the term “alkenyl” refersto an unbranched, branched or cyclic hydrocarbyl residue having one ormore carbon-carbon double bonds. As used herein, the term “alkynyl”refers to an unbranched, branched, or cyclic hydrocarbyl residue havingone or more carbon-carbon triple bonds; the residue can also include oneor more double bonds. With respect to the use of “alkenyl” or “alkynyl,”the presence of multiple double bonds cannot produce an aromatic ring.As used herein, the terms “hydroxyalkyl,” “hydroxyalkenyl,” and“hydroxyalkynyl,” respectively, refer to an alkyl, alkenyl, or alkynylgroup including one or more hydroxyl groups as substituents; as detailedbelow, further substituents can be optionally included. As used herein,the term “aryl” refers to a monocyclic or fused bicyclic moiety havingthe well-known characteristics of aromaticity; examples include phenyland naphthyl, which can be optionally substituted. As used herein, theterm “hydroxyaryl” refers to an aryl group including one or morehydroxyl groups as substituents; as further detailed below, furthersubstituents can be optionally included. As used herein, the term“heteroaryl” refers to monocyclic or fused bicylic ring systems thathave the characteristics of aromaticity and include one or moreheteroatoms selected from O, S, and N. The inclusion of a heteroatompermits aromaticity in 5-membered rings as well as in 6-membered rings.Typical heteroaromatic systems include monocyclic C₅-C₆ heteroaromaticgroups such as pyridyl, pyrimidyl, pyrazinyl, thienyl, furanyl,pyrrolyl, pyrazolyl, thiazolyl, oxazolyl, triazolyl, triazinyl,tetrazolyl, tetrazinyl, and imidazolyl, as well as the fused bicyclicmoieties formed by fusing one of these monocyclic heteroaromatic groupswith a phenyl ring or with any of the heteroaromatic monocyclic groupsto form a C₈-C₁₀ bicyclic group such as indolyl, benzimidazolyl,indazolyl, benzotriazolyl, isoquinolyl, quinolyl, benzothiazolyl,benzofuranyl, pyrazolylpyridyl, quinazolinyl, quinoxalinyl, cinnolinyl,and other ring systems known in the art. Any monocyclic or fused ringbicyclic system that has the characteristics of aromaticity in terms ofdelocalized electron distribution throughout the ring system is includedin this definition. This definition also includes bicyclic groups whereat least the ring that is directly attached to the remainder of themolecule has the characteristics of aromaticity, including thedelocalized electron distribution that is characteristic of aromaticity.Typically the ring systems contain 5 to 12 ring member atoms and up tofour heteroatoms, wherein the heteroatoms are selected from the groupconsisting of N, O, and S. Frequently, the monocyclic heteroarylscontain 5 to 6 ring members and up to three heteroatoms selected fromthe group consisting of N, O, and S; frequently, the bicyclicheteroaryls contain 8 to 10 ring members and up to four heteroatomsselected from the group consisting of N, O, and S. The number andplacement of heteroatoms in heteroaryl ring structures is in accordancewith the well-known limitations of aromaticity and stability, wherestability requires the heteroaromatic group to be stable enough to beexposed to water at physiological temperatures without rapiddegradation. As used herein, the term “hydroxheteroaryl” refers to aheteroaryl group including one or more hydroxyl groups as substituents;as further detailed below, further substituents can be optionallyincluded. As used herein, the terms “haloaryl” and “haloheteroaryl”refer to aryl and heteroaryl groups, respectively, substituted with atleast one halo group, where “halo” refers to a halogen selected from thegroup consisting of fluorine, chlorine, bromine, and iodine, typically,the halogen is selected from the group consisting of chlorine, bromine,and iodine; as detailed below, further substituents can be optionallyincluded. As used herein, the terms “haloalkyl,” “haloalkenyl,” and“haloalkynyl” refer to alkyl, alkenyl, and alkynyl groups, respectively,substituted with at least one halo group, where “halo” refers to ahalogen selected from the group consisting of fluorine, chlorine,bromine, and iodine, typically, the halogen is selected from the groupconsisting of chlorine, bromine, and iodine; as detailed below, furthersubstituents can be optionally included.

As used herein, the term “optionally substituted” indicates that theparticular group or groups referred to as optionally substituted mayhave no non-hydrogen substituents, or the group or groups may have oneor more non-hydrogen substituents consistent with the chemistry andpharmacological activity of the resulting molecule. If not otherwisespecified, the total number of such substituents that may be present isequal to the total number of hydrogen atoms present on the unsubstitutedform of the group being described; fewer than the maximum number of suchsubstituents may be present. Where an optional substituent is attachedvia a double bond, such as a carbonyl oxygen (C═O), the group takes uptwo available valences on the carbon atom to which the optionalsubstituent is attached, so the total number of substituents that may beincluded is reduced according to the number of available valiences. Asused herein, the term “substituted,” whether used as part of “optionallysubstituted” or otherwise, when used to modify a specific group, moiety,or radical, means that one or more hydrogen atoms are, each,independently of each other, replaced with the same or differentsubstituent or substituents.

Substituent groups useful for substituting saturated carbon atoms in thespecified group, moiety, or radical include, but are not limited to,—Z^(a), ═O, —OZ^(b), —SZ^(b), ═S⁻, —NZ^(c)Z^(c), ═NZ^(b), ═N═OZ^(b),trihalomethyl, —CF₃, —ON, —OCN, —SON, —NO, NO₂, ═N₂, —N₃, —S(O)₂Z^(b),—S(O)₂NZ^(b), —S(O₂)O⁻, —S(O₂)OZ^(b), —OS(O₂)OZ^(b), —OS(O₂)O⁻,—OS(O₂)OZ^(b), —P(O)(O⁻)₂, —P(O)(OZ^(b))(O⁻), —P(O)(OZ^(b))(OZ^(b)),—C(O)Z^(b), —C(S)Z^(b), —C(NZ^(b))Z^(b), —C(O)O⁻, —C(O)OZ^(b),—C(S)OZ^(b), —C(O)NZ^(c)Z^(c), —C(NZ^(b))NZ^(c)Z^(c), —OC(O)Z^(b),—OC(S)Z^(b), —OC(O)O⁻, —OC(O)OZ^(b), —OC(S)OZ^(b), —NZ^(b)C(O)Z^(b),—NZ^(b)C(S)Z^(b), —NZ^(b)C(O)O⁻, —NZ^(b)C(O)OZ^(b), —NZ^(b)C(S)OZ^(b),—NZ^(b)C(O)NZ^(c)Z^(c), —NZ^(b)C(NZ^(b))Z^(b),—NZ^(b)C(NZ^(b))NZ^(c)Z^(c), wherein Z^(a) is selected from the groupconsisting of alkyl, cycloalkyl, heteroalkyl, cycloheteroalkyl, aryl,arylalkyl, heteroaryl and heteroarylalkyl; each Z^(b) is independentlyhydrogen or Z^(a); and each Z^(c) is independently Z^(b) or,alternatively, the two Z^(c)'s may be taken together with the nitrogenatom to which they are bonded to form a 4-, 5-, 6-, or 7-memberedcycloheteroalkyl ring structure which may optionally include from 1 to 4of the same or different heteroatoms selected from the group consistingof N, O, and S. As specific examples, —NZ^(c)Z^(c) is meant to include—NH₂, —NH-alkyl, —N-pyrrolidinyl, and —N-morpholinyl, but is not limitedto those specific alternatives and includes other alternatives known inthe art. Similarly, as another specific example, a substituted alkyl ismeant to include -alkylene-O-alkyl, -alkylene-heteroaryl,-alkylene-cycloheteroaryl, -alkylene-C(O)OZ^(b),-alkylene-C(O)NZ^(b)Z^(b), and —CH₂—CH₂—C(O)—CH₃₃ but is not limited tothose specific alternatives and includes other alternatives known in theart. The one or more substituent groups, together with the atoms towhich they are bonded, may form a cyclic ring, including, but notlimited to, cycloalkyl and cycloheteroalkyl.

Similarly, substituent groups useful for substituting unsaturated carbonatoms in the specified group, moiety, or radical include, but are notlimited to, —Z^(a), halo, —O⁻, —OZ^(b), —SZ^(b), —S⁻, —NZ^(c)Z^(c),trihalomethyl, —CF₃, —ON, —OCN, —SCN, —NO, —NO₂, —N₃, —S(O)₂Z^(b),—S(O₂)O⁻, —S(O₂)OZ^(b), —OS(O₂)OZ^(b), —OS(O₂)O⁻, —P(O)(O⁻)₂,—P(O)(OZ^(b))(O⁻), —P(O)(OZ^(b))(OZ^(b)), —C(O)Z^(b), —C(S)Z^(b),—C(NZ^(b))Z^(b), —C(O)O⁻, —C(O)OZ^(b), —C(S)OZ^(b), —C(O)NZ^(c)Z^(c),—C(NZ^(b))NZ^(c)Z^(c), —OC(O)Z^(b), —OC(S)Z^(b), —OC(O)O⁻, —OC(O)OZ^(b),—OC(S)OZ^(b), —NZ^(b)C(O)OZ^(b), —NZ^(b)C(S)OZ^(b),—NZ^(b)C(O)NZ^(c)Z^(c), —NZ^(b)C(NZ^(b))Z^(b), and—NZ^(b)C(NZ^(b))NZ^(c)Z^(c), wherein Z^(a), Z^(b), and Z^(c) are asdefined above.

Similarly, substituent groups useful for substituting nitrogen atoms inheteroalkyl and cycloheteroalkyl groups include, but are not limited to,—Z^(a), halo, —O⁻, —OZ^(b), —SZ^(b), —S⁻, —NZ^(c)Z^(c), trihalomethyl,—CF₃, —CN, —OCN, —SCN, —NO, —NO₂, —S(O)₂Z^(b), —S(O₂)O⁻, —S(O₂)OZ^(b),—OS(O₂)OZ^(b), —OS(O₂)O⁻, —P(O)(O⁻)₂, —P(O)(OZ^(b))(O⁻),—P(O)(OZ^(b))(OZ^(b)), —C(O)Z^(b), —C(S)Z^(b), —C(NZ^(b))Z^(b),—C(O)OZ^(b), —C(S)OZ^(b), —C(O)NZ^(c)Z^(c), —C(NZ^(b))NZ^(c)Z^(c),—OC(O)Z^(b), —OC(S)Z^(b), —OC(O)OZ^(b), —OC(S)OZ^(b), —NZ^(b)C(O)Z^(b),—NZ^(b)C(S)Z^(b), —NZ^(b)C(O)OZ^(b), —NZ^(b)C(S)OZ^(b),—NZ^(b)C(O)NZ^(c)Z^(c), —NZ^(b)C(NZ^(b))Z^(b), and—NZ^(b)C(NZ^(b))NZ^(c)Z^(c), wherein Z^(a), Z^(b), and Z^(c) are asdefined above.

The compounds described herein may contain one or more chiral centersand/or double bonds and therefore, may exist as stereoisomers, such asdouble-bond isomers (i.e., geometric isomers such as E and Z),enantiomers or diastereomers. The invention includes each of theisolated stereoisomeric forms (such as the enantiomerically pureisomers, the E and Z isomers, and other alternatives for stereoisomers)as well as mixtures of stereoisomers in varying degrees of chiral purityor percentage of E and Z, including racemic mixtures, mixtures ofdiastereomers, and mixtures of E and Z isomers. Accordingly, thechemical structures depicted herein encompass all possible enantiomersand stereoisomers of the illustrated compounds including thestereoisomerically pure form (e.g., geometrically pure, enantiomericallypure or diastereomerically pure) and enantiomeric and stereoisomericmixtures. Enantiomeric and stereoisomeric mixtures can be resolved intotheir component enantiomers or stereoisomers using separation techniquesor chiral synthesis techniques well known to the skilled artisan. Theinvention includes each of the isolated stereoisomeric forms as well asmixtures of stereoisomers in varying degrees of chiral purity, includingracemic mixtures. It also encompasses the various diastereomers. Otherstructures may appear to depict a specific isomer, but that is merelyfor convenience, and is not intended to limit the invention to thedepicted isomer. When the chemical name does not specify the isomericform of the compound, it denotes any one of the possible isomeric formsor mixtures of those isomeric forms of the compound.

The compounds may also exist in several tautomeric forms, and thedepiction herein of one tautomer is for convenience only, and is alsounderstood to encompass other tautomers of the form shown. Accordingly,the chemical structures depicted herein encompass all possibletautomeric forms of the illustrated compounds. The term “tautomer” asused herein refers to isomers that change into one another with greatease so that they can exist together in equilibrium; the equilibrium maystrongly favor one of the tautomers, depending on stabilityconsiderations. For example, ketone and enol are two tautomeric forms ofone compound.

As used herein, the term “solvate” means a compound formed by solvation(the combination of solvent molecules with molecules or ions of thesolute), or an aggregate that consists of a solute ion or molecule,i.e., a compound of the invention, with one or more solvent molecules.When water is the solvent, the corresponding solvate is “hydrate.”Examples of hydrate include, but are not limited to, hemihydrate,monohydrate, dihydrate, trihydrate, hexahydrate, and otherwater-containing species. It should be understood by one of ordinaryskill in the art that the pharmaceutically acceptable salt, and/orprodrug of the present compound may also exist in a solvate form. Thesolvate is typically formed via hydration which is either part of thepreparation of the present compound or through natural absorption ofmoisture by the anhydrous compound of the present invention.

As used herein, the term “ester” means any ester of a present compoundin which any of the —COOH functions of the molecule is replaced by a—COOR function, in which the R moiety of the ester is anycarbon-containing group which forms a stable ester moiety, including butnot limited to alkyl, alkenyl, alkynyl, cycloalkyl, cycloalkylalkyl,aryl, arylalkyl, heterocyclyl, heterocyclylalkyl and substitutedderivatives thereof. The hydrolysable esters of the present compoundsare the compounds whose carboxyls are present in the form ofhydrolysable ester groups. That is, these esters are pharmaceuticallyacceptable and can be hydrolyzed to the corresponding carboxyl acid invivo.

In addition to the substituents described above, alkyl, alkenyl andalkynyl groups can alternatively or in addition be substituted by C₁-C₈acyl, C₂-C₈ heteroacyl, C₆-C₁₀ aryl, C₃-C₈ cycloalkyl, C₃-C₈heterocyclyl, or C₅-C₁₀ heteroaryl, each of which can be optionallysubstituted. Also, in addition, when two groups capable of forming aring having 5 to 8 ring members are present on the same or adjacentatoms, the two groups can optionally be taken together with the atom oratoms in the substituent groups to which they are attached to form sucha ring.

“Heteroalkyl,” “heteroalkenyl,” and “heteroalkynyl” and the like aredefined similarly to the corresponding hydrocarbyl (alkyl, alkenyl andalkynyl) groups, but the ‘hetero’ terms refer to groups that contain 1-3O, S or N heteroatoms or combinations thereof within the backboneresidue; thus at least one carbon atom of a corresponding alkyl,alkenyl, or alkynyl group is replaced by one of the specifiedheteroatoms to form, respectively, a heteroalkyl, heteroalkenyl, orheteroalkynyl group. For reasons of chemical stability, it is alsounderstood that, unless otherwise specified, such groups do not includemore than two contiguous heteroatoms except where an oxo group ispresent on N or S as in a nitro or sulfonyl group.

While “alkyl” as used herein includes cycloalkyl and cycloalkylalkylgroups, the term “cycloalkyl” may be used herein to describe acarbocyclic non-aromatic group that is connected via a ring carbon atom,and “cycloalkylalkyl” may be used to describe a carbocyclic non-aromaticgroup that is connected to the molecule through an alkyl linker.

Similarly, “heterocyclyl” may be used to describe a non-aromatic cyclicgroup that contains at least one heteroatom (typically selected from N,O and S) as a ring member and that is connected to the molecule via aring atom, which may be C (carbon-linked) or N (nitrogen-linked); and“heterocyclylalkyl” may be used to describe such a group that isconnected to another molecule through a linker. The heterocyclyl can befully saturated or partially saturated, but non-aromatic. The sizes andsubstituents that are suitable for the cycloalkyl, cycloalkylalkyl,heterocyclyl, and heterocyclylalkyl groups are the same as thosedescribed above for alkyl groups. The heterocyclyl groups typicallycontain 1, 2 or 3 heteroatoms, selected from N, O and S as ring members;and the N or S can be substituted with the groups commonly found onthese atoms in heterocyclic systems. As used herein, these terms alsoinclude rings that contain a double bond or two, as long as the ringthat is attached is not aromatic. The substituted cycloalkyl andheterocyclyl groups also include cycloalkyl or heterocyclic rings fusedto an aromatic ring or heteroaromatic ring, provided the point ofattachment of the group is to the cycloalkyl or heterocyclyl ring ratherthan to the aromatic/heteroaromatic ring.

As used herein, “acyl” encompasses groups comprising an alkyl, alkenyl,alkynyl, aryl or arylalkyl radical attached at one of the two availablevalence positions of a carbonyl carbon atom, and heteroacyl refers tothe corresponding groups wherein at least one carbon other than thecarbonyl carbon has been replaced by a heteroatom chosen from N, O andS.

Acyl and heteroacyl groups are bonded to any group or molecule to whichthey are attached through the open valence of the carbonyl carbon atom.Typically, they are C₁-C₈ acyl groups, which include formyl, acetyl,pivaloyl, and benzoyl, and C₂-C₈ heteroacyl groups, which includemethoxyacetyl, ethoxycarbonyl, and 4-pyridinoyl.

Similarly, “arylalkyl” and “heteroarylalkyl” refer to aromatic andheteroaromatic ring systems which are bonded to their attachment pointthrough a linking group such as an alkylene, including substituted orunsubstituted, saturated or unsaturated, cyclic or acyclic linkers.Typically the linker is C₁-C₈ alkyl. These linkers may also include acarbonyl group, thus making them able to provide substituents as an acylor heteroacyl moiety. An aryl or heteroaryl ring in an arylalkyl orheteroarylalkyl group may be substituted with the same substituentsdescribed above for aryl groups. Preferably, an arylalkyl group includesa phenyl ring optionally substituted with the groups defined above foraryl groups and a C₁-C₄ alkylene that is unsubstituted or is substitutedwith one or two C₁-C₄ alkyl groups or heteroalkyl groups, where thealkyl or heteroalkyl groups can optionally cyclize to form a ring suchas cyclopropane, dioxolane, or oxacyclopentane. Similarly, aheteroarylalkyl group preferably includes a C₅-C₆ monocyclic heteroarylgroup that is optionally substituted with the groups described above assubstituents typical on aryl groups and a C₁-C₄ alkylene that isunsubstituted or is substituted with one or two C₁-C₄ alkyl groups orheteroalkyl groups, or it includes an optionally substituted phenyl ringor C₅-C₆ monocyclic heteroaryl and a C₁-C₄ heteroalkylene that isunsubstituted or is substituted with one or two C₁-C₄ alkyl orheteroalkyl groups, where the alkyl or heteroalkyl groups can optionallycyclize to form a ring such as cyclopropane, dioxolane, oroxacyclopentane.

Where an arylalkyl or heteroarylalkyl group is described as optionallysubstituted, the substituents may be on either the alkyl or heteroalkylportion or on the aryl or heteroaryl portion of the group. Thesubstituents optionally present on the alkyl or heteroalkyl portion arethe same as those described above for alkyl groups generally; thesubstituents optionally present on the aryl or heteroaryl portion arethe same as those described above for aryl groups generally.

“Arylalkyl” groups as used herein are hydrocarbyl groups if they areunsubstituted, and are described by the total number of carbon atoms inthe ring and alkylene or similar linker. Thus a benzyl group is aC7-arylalkyl group, and phenylethyl is a C8-arylalkyl.

“Heteroarylalkyl” as described above refers to a moiety comprising anaryl group that is attached through a linking group, and differs from“arylalkyl” in that at least one ring atom of the aryl moiety or oneatom in the linking group is a heteroatom selected from N, O and S. Theheteroarylalkyl groups are described herein according to the totalnumber of atoms in the ring and linker combined, and they include arylgroups linked through a heteroalkyl linker; heteroaryl groups linkedthrough a hydrocarbyl linker such as an alkylene; and heteroaryl groupslinked through a heteroalkyl linker. Thus, for example,C7-heteroarylalkyl would include pyridylmethyl, phenoxy, andN-pyrrolylmethoxy.

“Alkylene” as used herein refers to a divalent hydrocarbyl group;because it is divalent, it can link two other groups together. Typicallyit refers to —(CH₂)_(n)— where n is 1-8 and preferably n is 1-4, thoughwhere specified, an alkylene can also be substituted by other groups,and can be of other lengths, and the open valences need not be atopposite ends of a chain.

In general, any alkyl, alkenyl, alkynyl, acyl, or aryl or arylalkylgroup that is contained in a substituent may itself optionally besubstituted by additional substituents. The nature of these substituentsis similar to those recited with regard to the primary substituentsthemselves if the substituents are not otherwise described.

“Amino” as used herein refers to —NH₂, but where an amino is describedas “substituted” or “optionally substituted”, the term includes NR′R″wherein each R′ and R″ is independently H, or is an alkyl, alkenyl,alkynyl, acyl, aryl, or arylalkyl group, and each of the alkyl, alkenyl,alkynyl, acyl, aryl, or arylalkyl groups is optionally substituted withthe substituents described herein as suitable for the correspondinggroup; the R′ and R″ groups and the nitrogen atom to which they areattached can optionally form a 3- to 8-membered ring which may besaturated, unsaturated or aromatic and which contains 1-3 heteroatomsindependently selected from N, O and S as ring members, and which isoptionally substituted with the substituents described as suitable foralkyl groups or, if NR′R″ is an aromatic group, it is optionallysubstituted with the substituents described as typical for heteroarylgroups.

As used herein, the term “carbocycle,” “carbocyclyl,” or “carbocyclic”refers to a cyclic ring containing only carbon atoms in the ring,whereas the term “heterocycle” or “heterocyclic” refers to a ringcomprising a heteroatom. The carbocyclyl can be fully saturated orpartially saturated, but non-aromatic. For example, the carbocyclylencompasses cycloalkyl. The carbocyclic and heterocyclic structuresencompass compounds having monocyclic, bicyclic or multiple ringsystems; and such systems may mix aromatic, heterocyclic, andcarbocyclic rings. Mixed ring systems are described according to thering that is attached to the rest of the compound being described.

As used herein, the term “heteroatom” refers to any atom that is notcarbon or hydrogen, such as nitrogen, oxygen or sulfur. When it is partof the backbone or skeleton of a chain or ring, a heteroatom must be atleast divalent, and will typically be selected from N, O, P, and S.

As used herein, the term “alkanoyl” refers to an alkyl group covalentlylinked to a carbonyl (C═O) group. The term “lower alkanoyl” refers to analkanoyl group in which the alkyl portion of the alkanoyl group isC₁-C₆. The alkyl portion of the alkanoyl group can be optionallysubstituted as described above. The term “alkylcarbonyl” canalternatively be used. Similarly, the terms “alkenylcarbonyl” and“alkynylcarbonyl” refer to an alkenyl or alkynyl group, respectively,linked to a carbonyl group.

As used herein, the term “alkoxy” refers to an alkyl group covalentlylinked to an oxygen atom; the alkyl group can be considered as replacingthe hydrogen atom of a hydroxyl group. The term “lower alkoxy” refers toan alkoxy group in which the alkyl portion of the alkoxy group is C₁-C₆.The alkyl portion of the alkoxy group can be optionally substituted asdescribed above. As used herein, the term “haloalkoxy” refers to analkoxy group in which the alkyl portion is substituted with one or morehalo groups.

As used herein, the term “sulfo” refers to a sulfonic acid (—SO₃H)substituent.

As used herein, the term “sulfamoyl” refers to a substituent with thestructure —S(O₂)NH₂, wherein the nitrogen of the NH₂ portion of thegroup can be optionally substituted as described above.

As used herein, the term “carboxyl” refers to a group of the structure—C(O₂)H.

As used herein, the term “carbamyl” refers to a group of the structure—C(O₂)NH₂, wherein the nitrogen of the NH₂ portion of the group can beoptionally substituted as described above.

As used herein, the terms “monoalkylaminoalkyl” and “dialkylaminoalkyl”refer to groups of the structure -Alk₁-NH-Alk₂ and -Alk₁-N(Alk₂)(Alk₃),wherein Alk₁, Alk₂, and Alk₃ refer to alkyl groups as described above.

As used herein, the term “alkylsulfonyl” refers to a group of thestructure —S(O)₂-Alk wherein Alk refers to an alkyl group as describedabove. The terms “alkenylsulfonyl” and “alkynylsulfonyl” referanalogously to sulfonyl groups covalently bound to alkenyl and alkynylgroups, respectively. The term “arylsulfonyl” refers to a group of thestructure —S(O)₂—Ar wherein Ar refers to an aryl group as describedabove. The term “aryloxyalkylsulfonyl” refers to a group of thestructure —S(O)₂-Alk-O—Ar, where Alk is an alkyl group as describedabove and Ar is an aryl group as described above. The term“arylalkylsulfonyl” refers to a group of the structure —S(O)₂-AlkAr,where Alk is an alkyl group as described above and Ar is an aryl groupas described above.

As used herein, the term “alkyloxycarbonyl” refers to an estersubstituent including an alkyl group wherein the carbonyl carbon is thepoint of attachment to the molecule. An example is ethoxycarbonyl, whichis CH₃CH₂OC(O)—. Similarly, the terms “alkenyloxycarbonyl,”“alkynyloxycarbonyl,” and “cycloalkylcarbonyl” refer to similar estersubstituents including an alkenyl group, alkenyl group, or cycloalkylgroup respectively. Similarly, the term “aryloxycarbonyl” refers to anester substituent including an aryl group wherein the carbonyl carbon isthe point of attachment to the molecule. Similarly, the term“aryloxyalkylcarbonyl” refers to an ester substituent including an alkylgroup wherein the alkyl group is itself substituted by an aryloxy group.

Other combinations of substituents are known in the art and, aredescribed, for example, in U.S. Pat. No. 8,344,162 to Jung et al.,incorporated herein by this reference. For example, the term“thiocarbonyl” and combinations of substituents including “thiocarbonyl”include a carbonyl group in which a double-bonded sulfur replaces thenormal double-bonded oxygen in the group. The term “alkylidene” andsimilar terminology refer to an alkyl group, alkenyl group, alkynylgroup, or cycloalkyl group, as specified, that has two hydrogen atomsremoved from a single carbon atom so that the group is double-bonded tothe remainder of the structure.

For the aspects described below relating to improvement in thetherapeutic employment of a substituted hexitol derivative, typically,the substituted hexitol derivative is selected from the group consistingof dianhydrogalactitol, derivatives of dianhydrogalactitol,diacetyldianhydrogalactitol, derivatives of diacetyldianhydrogalactitol,dibromodulcitol, and derivatives of dibromodulcitol, unless otherwisespecified. Preferably, the substituted hexitol derivative isdianhydrogalactitol, unless otherwise specified. In some cases,derivatives of dianhydrogalactitol such as compound analogs or prodrugsare preferred, as stated below.

One aspect of the present invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations to the timethat the compound is administered, the use of dose-modifying agents thatcontrol the rate of metabolism of the compound, normal tissue protectiveagents, and other alterations. General examples include: variations ofinfusion schedules (e.g., bolus i.v. versus continuous infusion), theuse of lymphokines (e.g., G-CSF, GM-CSF, EPO) to increase leukocytecount for improved immune response or for preventing anemia caused bymyelosuppressive agents, or the use of rescue agents such as leucovorinfor 5-FU or thiosulfate for cisplatin treatment. Specific inventiveexamples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: continuous i.v.infusion for hours to days; biweekly administration; doses greater than5 mg/m²/day; progressive escalation of dosing from 1 mg/m²/day based onpatient tolerance; doses less than 1 mg/m² for greater than 14 days; useof caffeine to modulate metabolism; use of isoniazid to modulatemetabolism; single and multiple doses escalating from 5 mg/m²/day viabolus; oral doses below 30 or above 130 mg/m²; oral dosages up to 40mg/m² for 3 days and then a nadir/recovery period of 18-21 days; dosingat a lower level for an extended period (e.g., 21 days); dosing at ahigher level; dosing with a nadir/recovery period longer than 21 days;dosing at a level to achieve a concentration of the substituted hexitolderivative such as dianhydrogalactitol in the cerebrospinal fluid (CSF)of equal to or greater than 5 μM; dosing at a level to achieve acytotoxic concentration in the CSF; the use of a substituted hexitolderivative such as dianhydrogalactitol as a single cytotoxic agent;administration on a 33-day cycle with a cumulative dose of about 9mg/m²; administration on a 33-day cycle with a cumulative dose of about10 mg/m²; administration on a 33-day cycle with a cumulative dose ofabout 20 mg/m²; administration on a 33-day cycle with a cumulative doseof about 40 mg/m²; administration on a 33-day cycle with a cumulativedose of about 80 mg/m²; administration on a 33-day cycle with acumulative dose of about 160 mg/m²; administration on a 33-day cyclewith a cumulative dose of about 240 mg/m²; administration so that theplasma half-life is about 1-2 hours; administration so that the C_(max)is <200 ng/ml; and administration so that the substituted hexitolderivative has a half life of >20 hours in the cerebrospinal fluid.

Another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in theroute by which the compound is administered. General examples include:changing route from oral to intravenous administration and vice versa;or the use of specialized routes such as subcutaneous, intramuscular,intraarterial, intraperitoneal, intralesional, intralymphatic,intratumoral, intrathecal, intravesicular, intracranial. Specificinventive examples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: topicaladministration; oral administration; slow-release oral delivery;intrathecal administration; intraarterial administration; continuousinfusion; intermittent infusion; intravenous administration;administration through a longer infusion; administration through IVpush; and administration to maximize the concentration of thesubstituted hexitol derivative in the CSF.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol made by changes in the schedule of administration.General examples include: daily administration, biweekly administration,or weekly administration. Specific inventive examples for a substitutedhexitol derivative such as dianhydrogalactitol for treatment of GBMinclude: daily administration; weekly administration; weeklyadministration for three weeks; biweekly administration; biweeklyadministration for three weeks with a 1-2 week rest period; intermittentboost dose administration; daily administration for one week formultiple weeks; or administration on days 1, 2, and 3 of a 33-day cycle.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in thestage of disease at diagnosis/progression that the compound isadministered. General examples include: the use of chemotherapy fornon-resectable local disease, prophylactic use to prevent metastaticspread or inhibit disease progression or conversion to more malignantstages. Specific inventive examples for a substituted hexitol derivativesuch as dianhydrogalactitol for treatment of GBM include: use in anappropriate disease stage for GBM; use of the substituted hexitolderivative such as dianhydrogalactitol with angiogenesis inhibitors suchas Avastin, a VEGF inhibitor, to prevent or limit metastatic spread,especially in the central nervous system; the use of a substitutedhexitol derivative such as dianhydrogalactitol for newly diagnoseddisease; the use of a substituted hexitol derivative such asdianhydrogalactitol for recurrent disease; the use of a substitutedhexitol derivative such as dianhydrogalactitol for resistant orrefractory disease; or the use of a substituted hexitol derivative suchas dianhydrogalactitol for childhood glioblastoma.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations to the typeof patient that would best tolerate or benefit from the use of thecompound. General examples include: use of pediatric doses for elderlypatients, altered doses for obese patients; exploitation of co-morbiddisease conditions such as diabetes, cirrhosis, or other conditions thatmay uniquely exploit a feature of the compound. Specific inventiveexamples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: patients with adisease condition characterized by a high level of a metabolic enzymeselected from the group consisting of histone deacetylase and ornithinedecarboxylase; patients with a low or high susceptibility to a conditionselected from the group consisting of thrombocytopenia and neutropenia;patients intolerant of GI toxicities; patients characterized by over- orunder-expression of a gene selected from the group consisting of c-Jun,a GPCR, a signal transduction protein, VEGF, a prostate-specific gene,and a protein kinase; prostate-specific gene, and a protein kinase;patients characterized by carrying extra copies of the EGFR gene forGBM; patients characterized by mutations in at least one gene selectedfrom the group consisting of TP53, PDGFRA, IDH1, and NF1 for GBM;patients characterized by methylation or lack of methylation of thepromoter of the MGMT gene; patients characterized by the existence of anIDH1 mutation; patients characterized by the presence of IDH1 wild-typegene; patients characterized by the presence of 1p/19q co-deletion;patients characterized by a high expression of MGMT; patientscharacterized by a low expression of MGMT; or patients characterized bya mutation in EGFR including, but not limited to, EGFR Variant III.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by more preciseidentification of a patient's ability to tolerate, metabolize andexploit the use of the compound as associated with a particularphenotype of the patient. General examples include: use of diagnostictools and kits to better characterize a patient's ability toprocess/metabolize a chemotherapeutic agent or the susceptibility of thepatient to toxicity caused by potential specialized cellular, metabolic,or organ system phenotypes. Specific inventive examples for asubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM include: use of a diagnostic tool, a diagnostic technique, adiagnostic kit, or a diagnostic assay to confirm a patient's particularphenotype; use of a method for measurement of a marker selected from thegroup consisting of histone deacetylase, ornithine decarboxylase, VEGF,a protein that is a gene product of jun, and a protein kinase; surrogatecompound testing; or low dose pre-testing for enzymatic status.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by more preciseidentification of a patient's ability to tolerate, metabolize andexploit the use of the compound as associated with a particular genotypeof the patient. General examples include: biopsy samples of tumors ornormal tissues (e.g., glial cells or other cells of the central nervoussystem) that may also be taken and analyzed to specifically tailor ormonitor the use of a particular drug against a gene target; studies ofunique tumor gene expression patterns; or analysis of SNP's (singlenucleotide polymorphisms), to enhance efficacy or to avoid particulardrug-sensitive normal tissue toxicities. Specific inventive examples fora substituted hexitol derivative such as dianhydrogalactitol fortreatment of GBM include: diagnostic tools, techniques, kits and assaysto confirm a patient's particular genotype; gene/protein expressionchips and analysis; Single Nucleotide Polymorphisms (SNP's) assessment;SNP's for histone deacetylase, ornithine decarboxylase, GPCR's, proteinkinases, telomerase, or jun; identification and measurement ofmetabolism enzymes and metabolites; determination of mutation of PDGFRAgene; determination of mutation of IDH1 gene; determination of mutationof NF1 gene; determination of copy number of the EGFR gene;determination of status of methylation of promoter of MGMT gene; use fordisease characterized by an IDH1 mutation; use for disease characterizedby IDH1 wild-type; use for disease characterized by 1p/19q co-deletion;use for disease where the 1p/19q co-deletion is not present; use fordisease characterized by an unmethylated promoter region of the MGMTgene; use for disease characterized by a methylated promoter region ofthe MGMT gene; use for disease characterized by high expression of MGMT;or use for disease characterized by low expression of MGMT.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by specialized preparationof a patient prior to or after the use of a chemotherapeutic agent.General examples include: induction or inhibition of metabolizingenzymes, specific protection of sensitive normal tissues or organsystems. Specific inventive examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM include: theuse of colchicine or analogs; use of diuretics such as probenecid; useof a uricosuric; use of uricase; non-oral use of nicotinamide; sustainedrelease forms of nicotinamide; use of inhibitors of poly (ADP ribose)polymerase; use of caffeine; leucovorin rescue; infection control;antihypertensives.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by use of additional drugsor procedures to prevent or reduce potential side-effects or toxicities.General examples include: the use of anti-emetics, anti-nausea,hematological support agents to limit or prevent neutropenia, anemia,thrombocytopenia, vitamins, antidepressants, treatments for sexualdysfunction, and other supportive techniques. Specific inventiveexamples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: the use of colchicineor analogs; use of diuretics such as probenecid; use of a uricosuric;use of uricase; non-oral use of nicotinamide; use of sustained releaseforms of nicotinamide; use of inhibitors of poly ADP-ribose polymerase;use of caffeine; leucovorin rescue; use of sustained releaseallopurinol; non-oral use of allopurinol; use of bone marrowtransplants; use of a blood cell stimulant; use of blood or plateletinfusions; use of filgrastim, G-CSF, or GM-CSF; use of pain managementtechniques; use of anti-inflammatories; use of fluids; use ofcorticosteroids; use of insulin control medications; use ofantipyretics; use of anti-nausea treatments; use of anti-diarrhealtreatment; use of N-acetylcysteine; or use of antihistamines.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by the use of monitoringdrug levels after dosing in an effort to maximize a patient's drugplasma level, to monitor the generation of toxic metabolites, monitoringof ancillary medicines that could be beneficial or harmful in terms ofdrug-drug interactions. General examples include: the monitoring of drugplasma protein binding, and monitoring of other pharmacokinetic orpharmacodynamic variables. Specific inventive examples for a substitutedhexitol derivative such as dianhydrogalactitol for treatment of GBMinclude: multiple determinations of drug plasma levels; or multipledeterminations of metabolites in the blood or urine.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by exploiting unique drugcombinations that may provide a more than additive or synergisticimprovement in efficacy or side-effect management. Specific inventiveexamples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: use with topoisomeraseinhibitors; use with fraudulent nucleosides; use with fraudulentnucleotides; use with thymidylate synthetase inhibitors; use with signaltransduction inhibitors; use with cisplatin or platinum analogs; usewith alkylating agents such as the nitrosoureas (BCNU, Gliadel wafers,CCNU, nimustine (ACNU), bendamustine (Treanda)); use with alkylatingagents that damage DNA at a different place than does DAG (TMZ, BCNU,CCNU, and other alkylating agents all damage DNA at O⁶ of guanine,whereas DAG cross-links at N⁷); use with a monofunctional alkylatingagent; use with a bifunctional alkylating agent; use with anti-tubulinagents; use with antimetabolites; use with berberine; use with apigenin;use with amonafide; use with colchicine or analogs; use with genistein;use with etoposide; use with cytarabine; use with camptothecins; usewith vinca alkaloids; use with topoisomerase inhibitors; use with5-fluorouracil; use with curcumin; use with NF-κB inhibitors; use withrosmarinic acid; use with mitoguazone; use with tetrandrine; use withtemozolomide (TMZ); use with biological therapies such as antibodiessuch as Avastin (a VEGF inhibitor), Rituxan, Herceptin, Erbitux; usewith epidermal growth factor receptor (EGFR) inhibitors; use withtyrosine kinase inhibitors; use with poly (ADP-ribose) polymerase (PARP)inhibitors; or use with cancer vaccine therapy.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by exploiting thesubstituted hexitol derivative such as dianhydrogalactitol as achemosensitizer where no measureable activity is observed when usedalone but in combination with other therapeutics a more than additive orsynergistic improvement in efficacy is observed. Specific inventiveexamples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: as a chemosensitizerin combination with topoisomerase inhibitors; as a chemosensitizer incombination with fraudulent nucleosides; as a chemosensitizer incombination with fraudulent nucleotides; as a chemosensitizer incombination with thymidylate synthetase inhibitors; as a chemosensitizerin combination with signal transduction inhibitors; as a chemosensitizerin combination with cisplatin or platinum analogs; as a chemosensitizerin combination with alkylating agents such as BCNU, BCNU wafers,Gliadel, CCNU, bendamustine (Treanda), or Temozolomide (Temodar); as achemosensitizer in combination with anti-tubulin agents; as achemosensitizer in combination with antimetabolites; as achemosensitizer in combination with berberine; as a chemosensitizer incombination with apigenin; as a chemosensitizer in combination withamonafide; as a chemosensitizer in combination with colchicine oranalogs; as a chemosensitizer in combination with genistein; as achemosensitizer in combination with etoposide; as a chemosensitizer incombination with cytarabine; as a chemosensitizer in combination withcamptothecins; as a chemosensitizer in combination with vinca alkaloids;as a chemosensitizer in combination with topoisomerase inhibitors; as achemosensitizer in combination with 5-fluorouracil; as a chemosensitizerin combination with curcumin; as a chemosensitizer in combination withNF-κB inhibitors; as a chemosensitizer in combination with rosmarinicacid; as a chemosensitizer in combination with mitoguazone; as achemosensitizer in combination with tetrandrine; as a chemosensitizer incombination with a tyrosine kinase inhibitor; as a chemosensitizer incombination with an EGFR inhibitor; or as a chemosensitizer incombination with an inhibitor of poly (ADP-ribose) polymerase (PARP).

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by exploiting thesubstituted hexitol derivative such as dianhydrogalactitol as achemopotentiator where minimal therapeutic activity is observed alonebut in combination with other therapeutics a more than additive orsynergistic improvement in efficacy is observed. Specific inventiveexamples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: as a chemopotentiatorin combination with topoisomerase inhibitors; as a chemopotentiator incombination with fraudulent nucleosides; as a chemopotentiator incombination with thymidylate synthetase inhibitors; as achemopotentiator in combination with signal transduction inhibitors; asa chemopotentiator in combination with cisplatin or platinum analogs; asa chemopotentiator in combination with use with alkylating agents suchas BCNU, BCNU wafers, Gliadel, or bendamustine (Treanda); as achemopotentiator in combination with anti-tubulin agents; as achemopotentiator in combination with antimetabolites; as achemopotentiator in combination with berberine; as a chemopotentiator incombination with apigenin; as a chemopotentiator in combination withamonafide; as a chemopotentiator in combination with colchicine oranalogs; as a chemopotentiator in combination with genistein; as achemopotentiator in combination with etoposide; as a chemopotentiator incombination with cytarabine; as a chemopotentiator in combination withcamptothecins; as a chemopotentiator in combination with vincaalkaloids; as a chemopotentiator in combination with topoisomeraseinhibitors; as a chemopotentiator in combination with 5-fluorouracil; asa chemopotentiator in combination with curcumin; as a chemopotentiatorin combination with NF-κB inhibitors; as a chemopotentiator incombination with rosmarinic acid; as a chemopotentiator in combinationwith mitoguazone; as a chemopotentiator in combination with tetrandrine;as a chemopotentiator in combination with a tyrosine kinase inhibitor;as a chemopotentiator in combination with an EGFR inhibitor; or as achemopotentiator in combination with an inhibitor of poly (ADP-ribose)polymerase (PARP).

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by drugs, treatments anddiagnostics to allow for the maximum benefit to patients treated with acompound. General examples include: pain management, nutritionalsupport, anti-emetics, anti-nausea therapies, anti-anemia therapy,anti-inflammatories. Specific inventive examples for a substitutedhexitol derivative such as dianhydrogalactitol for treatment of GBMinclude: use with therapies associated with pain management; nutritionalsupport; anti-emetics; anti-nausea therapies; anti-anemia therapy;anti-inflammatories: antipyretics; immune stimulants.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by the use ofcomplementary therapeutics or methods to enhance effectiveness or reduceside effects. Specific inventive examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM include:hypnosis; acupuncture; meditation; herbal medications created eithersynthetically or through extraction including NF-κB inhibitors (such asparthenolide, curcumin, rosmarinic acid); natural anti-inflammatories(including rhein, parthenolide); immunostimulants (such as those foundin Echinacea); antimicrobials (such as berberine); flavonoids,isoflavones, and flavones (such as apigenenin, genistein, genistin,6″-O-malonylgenistin, 6″-O-acetylgenistin, daidzein, daidzin,6″-O-malonyldaidzin, 6″-O-acetylgenistin, glycitein, glycitin,6″-O-malonylglycitin, and 6-O-acetylglycitin); applied kinesiology.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in thepharmaceutical bulk substance. General examples include: salt formation,homogeneous crystalline structure, pure isomers. Specific inventiveexamples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: salt formation;homogeneous crystalline structure; pure isomers; increased purity; lowerresidual solvents; or lower heavy metals.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in thediluents used to solubilize and deliver/present the compound foradministration. General examples include: Cremophor-EL, cyclodextrinsfor poorly water soluble compounds. Specific inventive examples for asubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM include: use of emulsions; dimethyl sulfoxide (DMSO);N-methylformamide (NMF); dimethylformamide (DMF); dimethylacetamide(DMA); ethanol; benzyl alcohol; dextrose containing water for injection;Cremophor; cyclodextrins; PEG.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in thesolvents used or required to solubilize a compound for administration orfor further dilution. General examples include: ethanol,dimethylacetamide (DMA). Specific inventive examples for a substitutedhexitol derivative such as dianhydrogalactitol for treatment of GBMinclude: the use of emulsions; DMSO; NMF; DMF; DMA; ethanol; benzylalcohol; dextrose containing water for injection; Cremophor;cyclodextrin; or PEG.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in thematerials/excipients, buffering agents, or preservatives required tostabilize and present a chemical compound for proper administration.General examples include: mannitol, albumin, EDTA, sodium bisulfite,benzyl alcohol. Specific inventive examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM include: theuse of mannitol; albumin; EDTA; sodium bisulfite; benzyl alcohol;carbonate buffers; phosphate buffers.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in thepotential dosage forms of the compound dependent on the route ofadministration, duration of effect, plasma levels required, exposure toside-effect normal tissues and metabolizing enzymes. General examplesinclude: tablets, capsules, topical gels, creams, patches,suppositories. Specific inventive examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM include: theuse of tablets; capsules; topical gels; topical creams; patches;suppositories; lyophilized dosage fills.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations in thedosage forms, container/closure systems, accuracy of mixing and dosagepreparation and presentation. General examples include: amber vials toprotect from light, stoppers with specialized coatings. Specificinventive examples for a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM include: the use of amber vialsto protect from light; stoppers with specialized coatings to improveshelf-life stability.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by the use of deliverysystems to improve the potential attributes of a pharmaceutical productsuch as convenience, duration of effect, reduction of toxicities.General examples include: nanocrystals, bioerodible polymers, liposomes,slow release injectable gels, microspheres. Specific inventive examplesfor a substituted hexitol derivative such as dianhydrogalactitol fortreatment of GBM include: the use of nanocrystals; bioerodible polymers;liposomes; slow release injectable gels; microspheres.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations to theparent molecule with covalent, ionic, or hydrogen bonded moieties toalter the efficacy, toxicity, pharmacokinetics, metabolism, or route ofadministration. General examples include: polymer systems such aspolyethylene glycols, polylactides, polyglycolides, amino acids,peptides, or multivalent linkers. Specific inventive examples for asubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM include: the use of polymer systems such as polyethylene glycols;polylactides; polyglycolides; amino acids; peptides; multivalentlinkers.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by alterations to themolecule such that improved pharmaceutical performance is gained with avariant of the active molecule in that after introduction into the bodya portion of the molecule is cleaved to reveal the preferred activemolecule. General examples include: enzyme sensitive esters, dimers,Schiff bases. Specific inventive examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM include: theuse of enzyme sensitive esters; dimers; Schiff bases; pyridoxalcomplexes; caffeine complexes.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by the use of additionalcompounds, biological agents that, when administered in the properfashion, a unique and beneficial effect can be realized. Generalexamples include: inhibitors of multi-drug resistance, specific drugresistance inhibitors, specific inhibitors of selective enzymes, signaltransduction inhibitors, repair inhibition. Specific inventive examplesfor a substituted hexitol derivative such as dianhydrogalactitol fortreatment of GBM include: the use of inhibitors of multi-drugresistance; specific drug resistance inhibitors; specific inhibitors ofselective enzymes; signal transduction inhibitors; repair inhibition;topoisomerase inhibitors with non-overlapping side effects.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by the use of thesubstituted hexitol derivative such as dianhydrogalactitol incombination as sensitizers/potentiators with biological responsemodifiers. General examples include: use in combination assensitizers/potentiators with biological response modifiers, cytokines,lymphokines, therapeutic antibodies, antisense therapies, genetherapies. Specific inventive examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM include: usein combination as sensitizers/potentiators with biological responsemodifiers; cytokines; lymphokines; therapeutic antibodies such asAvastin, Herceptin, Rituxan, and Erbitux; antisense therapies; genetherapies; ribozymes; RNA interference; or vaccines.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by exploiting theselective use of the substituted hexitol derivative such asdianhydrogalactitol to overcome developing or complete resistance to theefficient use of biotherapeutics. General examples include: tumorsresistant to the effects of biological response modifiers, cytokines,lymphokines, therapeutic antibodies, antisense therapies, genetherapies. Specific inventive examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM include: theuse against tumors resistant to the effects of biological responsemodifiers; cytokines; lymphokines; therapeutic antibodies; antisensetherapies; therapies such as Avastin, Rituxan, Herceptin, Erbitux; genetherapies; ribozymes; RNA interference; and vaccines.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by exploiting their use incombination with ionizing radiation, phototherapies, heat therapies, orradio-frequency generated therapies. General examples include: hypoxiccell sensitizers, radiation sensitizers/protectors, photosensitizers,radiation repair inhibitors. Specific inventive examples for asubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM include: use in combination with ionizing radiation; use incombination with hypoxic cell sensitizers; use in combination withradiation sensitizers/protectors; use in combination withphotosensitizers; use in combination with radiation repair inhibitors;use in combination with thiol depletion; use in combination withvaso-targeted agents; use in combination with use with radioactiveseeds; use in combination with radionuclides; use in combination withradiolabeled antibodies; use in combination with brachytherapy. This isuseful because radiation therapy is almost always undertaken early inthe treatment of GBM and improvements in the efficacy of such radiationtherapy or the ability to exert a synergistic effect by combiningradiation therapy with the administration of a substituted hexitolderivative such as dianhydrogalactitol is significant.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by optimizing its utilityby determining the various mechanisms of action, biological targets of acompound for greater understanding and precision to better exploit theutility of the molecule. Specific inventive examples for a substitutedhexitol derivative such as dianhydrogalactitol for treatment of GBMinclude: the use with inhibitors of poly-ADP ribose polymerase; agentsthat effect vasculature or vasodilation; oncogenic targeted agents;signal transduction inhibitors; EGFR inhibition; Protein Kinase Cinhibition; Phospholipase C downregulation; Jun downregulation; histonegenes; VEGF; ornithine decarboxylase; ubiquitin C; jun D; v-jun; GPCRs;protein kinase A; telomerase, prostate specific genes; protein kinasesother than protein kinase A; histone deacetylase; and tyrosine kinaseinhibitors.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by more preciseidentification and exposure of the compound to those select cellpopulations where the compound's effect can be maximally exploited,particularly GBM tumor cells. Specific inventive examples for asubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM include: use against radiation sensitive cells; use againstradiation resistant cells; or use against energy depleted cells.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by use of an agent thatcounteracts myelosuppression. Specific inventive examples for asubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM include use of dithiocarbamates to counteract myelosuppression.

Yet another aspect of the invention is an improvement in the therapeuticemployment of a substituted hexitol derivative such asdianhydrogalactitol for treatment of GBM made by use of an agent thatincreases the ability of the substituted hexitol to pass through theblood-brain barrier. Specific examples for a substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM includechimeric peptides; compositions comprising either avidin or an avidinfusion protein bonded to a biotinylated substituted hexitol derivative;neutral liposomes that are pegylated and that incorporate thesubstituted hexitol derivative and wherein the polyethylene glycolstrands are conjugated to at least one transportable peptide ortargeting agent; a humanized murine antibody that binds to the humaninsulin receptor linked to the substituted hexitol derivative through anavidin-biotin linkage; and a fusion protein linked to the hexitolthrough an avidin-biotin linkage.

Accordingly, one aspect of the present invention is a method to improvethe efficacy and/or reduce the side effects of the administration of asubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM comprising the steps of:

(1) identifying at least one factor or parameter associated with theefficacy and/or occurrence of side effects of the administration of thesubstituted hexitol derivative such as dianhydrogalactitol for treatmentof GBM; and

(2) modifying the factor or parameter to improve the efficacy and/orreduce the side effects of the administration of the substituted hexitolderivative such as dianhydrogalactitol for treatment of GBM.

Typically, the factor or parameter is selected from the group consistingof:

(1) dose modification;

(2) route of administration;

(3) schedule of administration;

(4) indications for use;

(5) selection of disease stage;

(6) other indications;

(7) patient selection;

(8) patient/disease phenotype;

(9) patient/disease genotype;

(10) pre/post-treatment preparation

(11) toxicity management;

(12) pharmacokinetic/pharmacodynamic monitoring;

(13) drug combinations;

(14) chemosensitization;

(15) chemopotentiation;

(16) post-treatment patient management;

(17) alternative medicine/therapeutic support;

(18) bulk drug product improvements;

(19) diluent systems;

(20) solvent systems;

(21) excipients;

(22) dosage forms;

(23) dosage kits and packaging;

(24) drug delivery systems;

(25) drug conjugate forms;

(26) compound analogs;

(27) prodrugs;

(28) multiple drug systems;

(29) biotherapeutic enhancement;

(30) biotherapeutic resistance modulation;

(31) radiation therapy enhancement;

(32) novel mechanisms of action;

(33) selective target cell population therapeutics;

(34) use of an agent that counteracts myelosuppression; and

(35) use of an agent that increases the ability of the substitutedhexitol to pass through the blood-brain barrier.

As detailed above, in general, the substituted hexitol derivative usablein methods and compositions according to the present invention includegalactitols, substituted galacitols, dulcitols, and substituteddulcitols, including dianhydrogalactitol, diacetyldianhydrogalactitol,dibromodulcitol, and derivatives and analogs thereof. Typically, thesubstituted hexitol derivative is selected from the group consisting ofdianhydrogalactitol, derivatives of dianhydrogalactitol,diacetyldianhydrogalactitol, derivatives of diacetyldianhydrogalactitol,dibromodulcitol, and derivatives of dibromodulcitol. Preferably, thesubstituted hexitol derivative is dianhydrogalactitol.

When the improvement made by is dose modification, the dose modificationcan be, but is not limited to, at least one dose modification selectedfrom the group consisting of:

-   -   (a) continuous i.v. infusion for hours to days;    -   (b) biweekly administration;    -   (c) doses greater than 5 mg/m²/day;    -   (d) progressive escalation of dosing from 1 mg/m²/day based on        patient tolerance;    -   (e) use of caffeine to modulate metabolism;    -   (f) use of isoniazid to modulate metabolism;    -   (g) selected and intermittent boosting of dosage administration;    -   (h) administration of single and multiple doses escalating from        5 mg/m²/day via bolus;    -   (i) oral dosages of below 30 mg/m²;    -   (j) oral dosages of above 130 mg/m²;    -   (k) oral dosages up to 40 mg/m² for 3 days and then a        nadir/recovery period of 18-21 days;    -   (l) dosing at a lower level for an extended period (e.g., 21        days);    -   (m) dosing at a higher level;    -   (n) dosing with a nadir/recovery period longer than 21 days;    -   (o) dosing at a level to achieve a concentration of the        substituted hexitol derivative such as dianhydrogalactitol in        the cerebrospinal fluid (CSF) of equal to or greater than 5 μM;    -   (p) dosing at a level to achieve a cytotoxic concentration in        the CSF;    -   (q) the use of a substituted hexitol derivative such as        dianhydrogalactitol as a single cytotoxic agent;    -   (r) administration on a 33-day cycle with a cumulative dose of        about 9 mg/m²;    -   (s) administration on a 33-day cycle with a cumulative dose of        about 10 mg/m²;    -   (t) administration on a 33-day cycle with a cumulative dose of        about 20 mg/m²;    -   (u) administration on a 33-day cycle with a cumulative dose of        about 40 mg/m²;    -   (v) administration on a 33-day cycle with a cumulative dose of        about 80 mg/m²;    -   (w) administration on a 33-day cycle with a cumulative dose of        about 160 mg/m²;    -   (x) administration on a 33-day cycle with a cumulative dose of        about 240 mg/m²;    -   (y) administration so that the plasma half-life is about 1-2        hours;

(xxvi) administration so that the C_(max) is <200 ng/ml; and

(xxvii) administration so that the substituted hexitol derivative has ahalf-life of >20 hours in the cerebrospinal fluid.

When the improvement is made by route of administration, the route ofadministration can be, but is not limited to, at least one route ofadministration selected from the group consisting of:

-   -   (a) topical administration;    -   (b) oral administration;    -   (c) slow release oral delivery;    -   (d) intrathecal administration;    -   (e) intraarterial administration;    -   (f) continuous infusion;    -   (g) intermittent infusion;    -   (h) intravenous administration, such as intravenous        administration for 30 minutes;    -   (i) administration through a longer infusion;    -   (j) administration through IV push; and    -   (k) administration to maximize the concentration of the        substituted hexitol derivative such as dianhydrogalactitol in        the CSF.

When the improvement is made by schedule of administration, the scheduleof administration can be, but is not limited to, at least one scheduleof administration selected from the group consisting of:

-   -   (a) daily administration;    -   (b) weekly administration;    -   (c) weekly administration for three weeks;    -   (d) biweekly administration;    -   (e) biweekly administration for three weeks with a 1-2 week rest        period;    -   (f) intermittent boost dose administration;    -   (g) daily administration for one week for multiple weeks; and    -   (h) administration on days 1, 2, and 3 of a 33-day cycle.

When the improvement is made by selection of disease stage, theselection of disease stage can be, but is not limited to, at least oneselection of disease stage selected from the group consisting of:

-   -   (a) use in an appropriate disease stage for GBM;    -   (b) use with an angiogenesis inhibitor to prevent or limit        metastatic spread;    -   (c) use for newly diagnosed disease;    -   (d) use for recurrent disease;    -   (e) use for resistant or refractory disease; and    -   (f) use for childhood glioblastoma.

When the improvement is made by patient selection, the patient selectioncan be, but is not limited to, a patient selection carried out by acriterion selected from the group consisting of:

-   -   (a) selecting patients with a disease condition characterized by        a high level of a metabolic enzyme selected from the group        consisting of histone deacetylase and ornithine decarboxylase;    -   (b) selecting patients with a low or high susceptibility to a        condition selected from the group consisting of thrombocytopenia        and neutropenia;    -   (c) selecting patients intolerant of GI toxicities;    -   (d) selecting patients characterized by over- or        under-expression of a gene selected from the group consisting of        c-Jun, a GPCR, a signal transduction protein, VEGF, a        prostate-specific gene, and a protein kinase.    -   (e) selecting patients characterized by carrying extra copies of        the EGFR gene for GBM;    -   (f) selecting patients characterized by mutations in at least        one gene selected from the group consisting of TP53, PDGFRA,        IDH1, and NF1 for GBM;    -   (g) selecting patients characterized by methylation or lack of        methylation of the promoter of the MGMT gene;    -   (h) selecting patients characterized by the existence of an IDH1        mutation;    -   (i) selecting patients characterized by the presence of IDH1        wild-type gene;    -   (j) selecting patients characterized by the presence of 1p/19q        co-deletion;    -   (k) selecting patients characterized by the absence of an 1p/19q        co-deletion;    -   (l) selecting patients characterized by an unmethylated promoter        region of MGMT (O⁶-methylguanine methyltransferase);    -   (m) selecting patients characterized by a methylated promoter        region of MGMT;    -   (n) selecting patients characterized by a high expression of        MGMT;    -   (o) selecting patients characterized by a low expression of        MGMT; and    -   (p) selecting patients characterized by a mutation in EGFR,        including, but not limited to EGFR Variant III.

The cellular proto-oncogene c-Jun encodes a protein that, in combinationwith c-Fos, forms the AP-1 early response transcription factor. Thisproto-oncogene plays a key role in transcription and interacts with alarge number of proteins affecting transcription and gene expression. Itis also involved in proliferation and apoptosis of cells that form partof a number of tissues, including cells of the endometrium and glandularepithelial cells. G-protein coupled receptors (GPCRs) are importantsignal transducing receptors. The superfamily of G protein coupledreceptors includes a large number of receptors. These receptors areintegral membrane proteins characterized by amino acid sequences thatcontain seven hydrophobic domains, predicted to represent thetransmembrane spanning regions of the proteins. They are found in a widerange of organisms and are involved in the transmission of signals tothe interior of cells as a result of their interaction withheterotrimeric G proteins. They respond to a diverse range of agentsincluding lipid analogues, amino acid derivatives, small molecules suchas epinephrine and dopamine, and various sensory stimuli. The propertiesof many known GPCR are summarized in S. Watson & S. Arkinstall, “TheG-Protein Linked Receptor Facts Book” (Academic Press, London, 1994),incorporated herein by this reference. GPCR receptors include, but arenot limited to, acetylcholine receptors, β-adrenergic receptors,β₃-adrenergic receptors, serotonin (5-hydroxytryptamine) receptors,dopamine receptors, adenosine receptors, angiotensin Type II receptors,bradykinin receptors, calcitonin receptors, calcitonin gene-relatedreceptors, cannabinoid receptors, cholecystokinin receptors, chemokinereceptors, cytokine receptors, gastrin receptors, endothelin receptors,γ-aminobutyric acid (GABA) receptors, galanin receptors, glucagonreceptors, glutamate receptors, luteinizing hormone receptors,choriogonadotrophin receptors, follicle-stimulating hormone receptors,thyroid-stimulating hormone receptors, gonadotrophin-releasing hormonereceptors, leukotriene receptors, Neuropeptide Y receptors, opioidreceptors, parathyroid hormone receptors, platelet activating factorreceptors, prostanoid (prostaglandin) receptors, somatostatin receptors,thyrotropin-releasing hormone receptors, vasopressin and oxytocinreceptors.

EGFR mutations can be associated with sensitivity to therapeutic agentssuch as gefitinib, as described in J. G. Paez et al., “EGFR Mutations inLung Cancer: Correlation with Clinical Response to Gefitinib,” Science304: 1497-1500 (2004), incorporated herein by this reference. Onespecific mutation in EGFR that is associated with resistance to tyrosinekinase inhibitors is known as EGFR Variant III, which is described in C.A. Learn et al., “Resistance to Tyrosine Kinase Inhibition by MutantEpidermal Growth Factor Variant III Contributes to the NeoplasticPhenotype of Glioblastoma Multiforme,” Clin. Cancer Res. 10: 3216-3224(2004), incorporated herein by this reference. EGFR Variant III ischaracterized by a consistent and tumor-specific in-frame deletion of801 by from the extracellular domain that splits a codon and produces anovel glycine at the fusion junction. This mutation encodes a proteinwith a constituently active thymidine kinase that enhances thetumorigenicity of the cells carrying this mutation. This mutated proteinsequence is clonally expressed on a significant proportion ofglioblastomas but is absent from normal tissues.

When the improvement is made by analysis of patient or diseasephenotype, the analysis of patient or disease phenotype can be, but isnot limited to, a method of analysis of patient or disease phenotypecarried out by a method selected from the group consisting of:

-   -   (a) use of a diagnostic tool, a diagnostic technique, a        diagnostic kit, or a diagnostic assay to confirm a patient's        particular phenotype;    -   (b) use of a method for measurement of a marker selected from        the group consisting of histone deacetylase, ornithine        decarboxylase, VEGF, a protein that is a gene product of jun,        and a protein kinase;    -   (c) surrogate compound dosing; and    -   (d) low dose pre-testing for enzymatic status.

When the improvement is made by analysis of patient or disease genotype,the analysis of patient or disease genotype can be, but is not limitedto, a method of analysis of patient or disease genotype carried out by amethod selected from the group consisting of:

-   -   (a) use of a diagnostic tool, a diagnostic technique, a        diagnostic kit, or a diagnostic assay to confirm a patient's        particular genotype;    -   (b) use of a gene chip;    -   (c) use of gene expression analysis;    -   (d) use of single nucleotide polymorphism (SNP) analysis;    -   (e) measurement of the level of a metabolite or a metabolic        enzyme;    -   (f) determination of mutation of PDGFRA gene;    -   (g) determination of mutation of IDH1 gene;    -   (h) determination of mutation of NF1 gene;    -   (i) determination of copy number of the EGFR gene;    -   (j) determination of status of methylation of promoter of MGMT        gene;    -   (k) determination of the existence of an IDH1 mutation;    -   (l) determination of the existence of IDH1 wild-type;    -   (m) determination of the existence of a 1p/19q co-deletion;    -   (n) determination of the absence of a 1p/19q co-deletion;    -   (o) determination of the existence of an unmethylated promoter        region of the MGMT gene;    -   (p) determination of the existence of a methylated promoter        region of the MGMT gene;    -   (q) determination of the existence of high expression of MGMT;        and    -   (r) determination of the existence of low expression of MGMT.

The use of gene chips is described in A. J. Lee & S. Ramaswamy, “DNAMicroarrays in Biological Discovery and Patient Care” in Essentials ofGenomic and Personalized Medicine (G. S. Ginsburg & H. F. Willard, eds.,Academic Press, Amsterdam, 2010), ch. 7, pp. 73-88, incorporated hereinby this reference.

When the method is the use of single nucleotide polymorphism (SNP)analysis, the SNP analysis can be carried out on a gene selected fromthe group consisting of histone deacetylase, ornithine decarboxylase,VEGF, a prostate specific gene, c-Jun, and a protein kinase. The use ofSNP analysis is described in S. Levy and Y.- H. Rogers, “DNA Sequencingfor the Detection of Human Genome Variation” in Essentials of Genomicand Personalized Medicine (G. S. Ginsburg & H. F. Willard, eds.,Academic Press, Amsterdam, 2010), ch. 3, pp. 27-37, incorporated hereinby this reference.

Still other genomic techniques such as copy number variation analysisand analysis of DNA methylation can be employed. Copy number variationanalysis is described in C. Lee et al., “Copy Number Variation and HumanHealth” in Essentials of Genomic and Personalized Medicine (G. S.Ginsburg & H. F. Willard, eds., Academic Press, Amsterdam, 2010), ch. 5,pp. 46-59, incorporated herein by this reference. This is particularlysignificant for GBM as an increase in copy number of EGFR is associatedwith particular subtypes of GBM. DNA methylation analysis is describedin S. Cottrell et al., “DNA Methylation Analysis: Providing New Insightinto Human Disease” in Essentials of Genomic and Personalized Medicine(G. S. Ginsburg & H. F. Willard, eds., Academic Press, Amsterdam, 2010),ch. 6, pp. 60-72, incorporated herein by this reference. This isparticularly significant for GBM in that the prognosis for GBM varieswith the degree of methylation of the promoter of the MGMT gene.

When the improvement is made by pre/post-treatment preparation, thepre/post-treatment preparation can be, but is not limited to, a methodof pre/post treatment preparation selected from the group consisting of:

-   -   (a) the use of colchicine or an analog thereof;    -   (b) the use of a diuretic;    -   (c) the use of a uricosuric;    -   (d) the use of uricase;    -   (e) the non-oral use of nicotinamide;    -   (f) the use of a sustained-release form of nicotinamide;    -   (g) the use of an inhibitor of poly-ADP ribose polymerase;    -   (h) the use of caffeine;    -   (i) the use of leucovorin rescue;    -   (j) infection control; and    -   (k) the use of an anti-hypertensive agent.

Uricosurics include, but are not limited to, probenecid, benzbromarone,and sulfinpyrazone. A particularly preferred uricosuric is probenecid.Uricosurics, including probenecid, may also have diuretic activity.Other diuretics are well known in the art, and include, but are notlimited to, hydrochlorothiazide, carbonic anhydrase inhibitors,furosemide, ethacrynic acid, amiloride, and spironolactone.

Poly-ADP ribose polymerase inhibitors are described in G. J. Southan &C. Szabó, “Poly(ADP-Ribose) Inhibitors,” Curr. Med. Chem. 10: 321-240(2003), incorporated herein by this reference, and include nicotinamide,3-aminobenzamide, substituted 3,4-dihydroisoquinolin-1(2H)-ones andisoquinolin-1(2H)-ones, benzimidazoles, indoles, phthalazin-1(2H)-ones,quinazolinones, isoindolinones, phenanthridinones, and other compounds.

Leucovorin rescue comprises administration of folinic acid (leucovorin)to patients in which methotrexate has been administered. Leucovorin is areduced form of folic acid that bypasses dihydrofolate reductase andrestores hematopoietic function. Leucovorin can be administered eitherintravenously or orally.

In one alternative, wherein the pre/post treatment is the use of auricosuric, the uricosuric is probenecid or an analog thereof.

When the improvement is made by toxicity management, the toxicitymanagement can be, but is not limited to, a method of toxicitymanagement selected from the group consisting of:

-   -   (a) the use of colchicine or an analog thereof;    -   (b) the use of a diuretic;    -   (c) the use of a uricosuric;    -   (d) the use of uricase;    -   (e) the non-oral use of nicotinamide;    -   (f) the use of a sustained-release form of nicotinamide;    -   (g) the use of an inhibitor of poly-ADP ribose polymerase;    -   (h) the use of caffeine;    -   (i) the use of leucovorin rescue;    -   (j) the use of sustained-release allopurinol;    -   (k) the non-oral use of allopurinol;    -   (l) the use of bone marrow transplants;    -   (m) the use of a blood cell stimulant;    -   (n) the use of blood or platelet infusions;    -   (o) the administration of an agent selected from the group        consisting of filgrastim, G-CSF, and GM-CSF;    -   (p) the application of a pain management technique;    -   (q) the administration of an anti-inflammatory agent;    -   (r) the administration of fluids;    -   (s) the administration of a corticosteroid;    -   (t) the administration of an insulin control medication;    -   (u) the administration of an antipyretic;    -   (v) the administration of an anti-nausea treatment;    -   (w) the administration of an anti-diarrheal treatment;    -   (x) the administration of N-acetylcysteine; and    -   (y) the administration of an antihistamine.

Filgrastim is a granulocytic colony-stimulating factor (G-CSF) analogproduced by recombinant DNA technology that is used to stimulate theproliferation and differentiation of granulocytes and is used to treatneutropenia; G-CSF can be used in a similar manner. GM-CSF isgranulocyte macrophage colony-stimulating factor and stimulates stemcells to produce granulocytes (eosinophils, neutrophils, and basophils)and monocytes; its administration is useful to prevent or treatinfection.

Anti-inflammatory agents are well known in the art and includecorticosteroids and non-steroidal anti-inflammatory agents (NSAIDs).Corticosteroids with anti-inflammatory activity include, but are notlimited to, hydrocortisone, cortisone, beclomethasone dipropionate,betamethasone, dexamethasone, prednisone, methylprednisolone,triamcinolone, fluocinolone acetonide, and fludrocortisone.Non-steroidal anti-inflammatory agents include, but are not limited to,acetylsalicylic acid (aspirin), sodium salicylate, choline magnesiumtrisalicylate, salsalate, diflunisal, sulfasalazine, olsalazine,acetaminophen, indomethacin, sulindac, tolmetin, diclofenac, ketorolac,ibuprofen, naproxen, flurbiprofen, ketoprofen, fenoprofin, oxaprozin,mefenamic acid, meclofenamic acid, piroxicam, meloxicam, nabumetone,rofecoxib, celecoxib, etodolac, nimesulide, aceclofenac, alclofenac,alminoprofen, amfenac, ampiroxicam, apazone, araprofen, azapropazone,bendazac, benoxaprofen, benzydamine, bermoprofen, benzpiperylon,bromfenac, bucloxic acid, bumadizone, butibufen, carprofen, cimicoxib,cinmetacin, cinnoxicam, clidanac, clofezone, clonixin, clopirac,darbufelone, deracoxib, droxicam, eltenac, enfenamic acid, epirizole,esflurbiprofen, ethenzamide, etofenamate, etoricoxib, felbinac,fenbufen, fenclofenac, fenclozic acid, fenclozine, fendosal, fentiazac,feprazone, filenadol, flobufen, florifenine, flosulide, flubichinmethanesulfonate, flufenamic acid, flufenisal, flunixin, flunoxaprofen,fluprofen, fluproquazone, furofenac, ibufenac, imrecoxib, indoprofen,isofezolac, isoxepac, isoxicam, licofelone, lobuprofen, lomoxicam,lonazolac, loxaprofen, lumaricoxib, mabuprofen, miroprofen,mofebutazone, mofezolac, morazone, nepafanac, niflumic acid, nitrofenac,nitroflurbiprofen, nitronaproxen, orpanoxin, oxaceprol, oxindanac,oxpinac, oxyphenbutazone, pamicogrel, parcetasal, parecoxib, parsalmide,pelubiprofen, pemedolac, phenylbutazone, pirazolac, pirprofen,pranoprofen, salicin, salicylamide, salicylsalicylic acid, satigrel,sudoxicam, suprofen, talmetacin, talniflumate, tazofelone, tebufelone,tenidap, tenoxicam, tepoxalin, tiaprofenic acid, tiaramide, tilmacoxib,tinoridine, tiopinac, tioxaprofen, tolfenamic acid, triflusal, tropesin,ursolic acid, valdecoxib, ximoprofen, zaltoprofen, zidometacin, andzomepirac, and the salts, solvates, analogues, congeners, bioisosteres,hydrolysis products, metabolites, precursors, and prodrugs thereof.

The clinical use of corticosteroids is described in B. P. Schimmer & K.L. Parker, “Adrenocorticotropic Hormone; Adrenocortical Steroids andTheir Synthetic Analogs; Inhibitors of the Synthesis and Actions ofAdrenocortical Hormones” in Goodman & Gilman's The Pharmacological Basisof Therapeutics (L. L. Brunton, ed., 11^(th) ed., McGraw-Hill, New York,2006), ch. 59, pp. 1587-1612, incorporated herein by this reference.

Anti-nausea treatments include, but are not limited to, ondansetron,metoclopramide, promethazine, cyclizine, hyoscine, dronabinol,dimenhydrinate, diphenhydramine, hydroxyzine, medizine, dolasetron,granisetron, palonosetron, ramosetron, domperidone, haloperidol,chlorpromazine, fluphenazine, perphenazine, prochlorperazine,betamethasone, dexamethasone, lorazepam, and thiethylperazine.

Anti-diarrheal treatments include, but are not limited to,diphenoxylate, difenoxin, loperamide, codeine, racecadotril, octreoside,and berberine.

N-acetylcysteine is an antioxidant and mucolytic that also providesbiologically accessible sulfur.

Poly-ADP ribose polymerase (PARP) inhibitors include, but are notlimited to: (1) derivatives of tetracycline as described in U.S. Pat.No. 8,338,477 to Duncan et al.; (2)3,4-dihydro-5-methyl-1(2H)-isoquinoline, 3-aminobenzamide,6-aminonicotinamide, and 8-hydroxy-2-methyl-4(3H)-quinazolinone, asdescribed in U.S. Pat. No. 8,324,282 by Gerson et al.; (3)6-(5H)-phenanthridinone and 1,5-isoquinolinediol, as described in U.S.Pat. No. 8,324,262 by Yuan et al.; (4)(R)-3-[2-(2-hydroxymethylpyrrolidin-1-yl)ethyl]-5-methyl-2H-isoquinolin-1-one,as described in U.S. Pat. No. 8,309,573 to Fujio et al.; (5)6-alkenyl-substituted 2-quinolinones, 6-phenylalkyl-substitutedquinolinones, 6-alkenyl-substituted 2-quinoxalinones,6-phenylalkyl-substituted 2-quinoxalinones, substituted6-cyclohexylalkyl substituted 2-quinolinones, 6-cyclohexylalkylsubstituted 2-quinoxalinones, substituted pyridones, quinazolinonederivatives, phthalazine derivatives, quinazolinedione derivatives, andsubstituted 2-alkyl quinazolinone derivatives, as described in U.S. Pat.No. 8,299,256 to Vialard et al.; (6) 5-bromoisoquinoline, as describedin U.S. Pat. No. 8,299,088 to Mateucci et al.; (7)5-bis-(2-chloroethyl)amino]-1-methyl-2-benzimidazolebutyric acid,4-iodo-3-nitrobenzamide,8-fluoro-5-(4-((methylamino)methyl)phenyl)-3,4-dihydro-2H-azepino[5,4,3-cd]indol-1(6H)-onephosphoric acid, andN-[3-(3,4-dihydro-4-oxo-1-phthalazinyl)phenyl]-4-morpholinebutanamidemethanesulfonate, as described in U.S. Pat. No. 8,227,807 to Gallagheret al.; (8) pyridazinone derivatives, as described in U.S. Pat. No.8,268,827 to Branca et al.; (9)4-[3-(4-cyclopropanecarbonyl-piperazine-1-carbonyl)-4-fluorobenzyl]-2H-phthalazin-1-one,as described in U.S. Pat. No. 8,247,416 to Menear et al.; (10) tetraazaphenalen-3-one compounds, as described in U.S. Pat. No. 8,236,802 to Xuet al.; (11) 2-substituted-1H-benzimidazole-4-carboxamides, as describedin U.S. Pat. No. 8,217,070 to Zhu et al.; (12) substituted 2-alkylquinazolinones, as described in U.S. Pat. No. 8,188,103 to Van der Aa etal.; (13) 1H-benzimidazole-4-carboxamides, as described in U.S. Pat. No.8,183,250 to Penning et al.; (14) indenoisoquinolinone analogs, asdescribed in U.S. Pat. No. 8,119,654 to Jagtap et al.; (15) benzoxazolecarboxamides, described in U.S. Pat. No. 8,088,760 to Chu et al; (16)diazabenzo[de]anthracen-3-one compounds, described in U.S. Pat. No.8,058,075 to Xu et al.; (17) dihydropyridophthalazinones, described inU.S. Pat. No. 8,012,976 to Wang et al., (18) substituted azaindoles,described in U.S. Pat. No. 8,008,491 to Jiang et al.; (19) fusedtricyclic compounds, described in U.S. Pat. No. 7,956,064 to Chua etal.; (20) substituted6a,7,8,9-tetrahydropyrido[3,2-e]pyrrolo[1,2-a]pyrazin-6(5H)-ones,described in U.S. Pat. No. 7,928,105 to Gangloff et al.; and (21)thieno[2,3-c]isoquinolines, described in U.S. Pat. No. 7,825,129, all ofwhich patents are incorporated herein by this reference. Other PARPinhibitors are known in the art.

When the improvement is made by pharmacokinetic/pharmacodynamicmonitoring, the pharmacokinetic/pharmacodynamic monitoring can be, butis not limited to a method selected from the group consisting of:

-   -   (a) multiple determinations of blood plasma levels; and    -   (b) multiple determinations of at least one metabolite in blood        or urine.

Typically, determination of blood plasma levels or determination of atleast one metabolite in blood or urine is carried out by immunoassays.Methods for performing immunoassays are well known in the art, andinclude radioimmunoassay, ELISA (enzyme-linked immunosorbent assay),competitive immunoassay, immunoassay employing lateral flow test strips,and other assay methods.

When the improvement is made by drug combination, the drug combinationcan be, but is not limited to, a drug combination selected from thegroup consisting of:

-   -   (a) use with topoisomerase inhibitors;    -   (b) use with fraudulent nucleosides;    -   (c) use with fraudulent nucleotides;    -   (d) use with thymidylate synthetase inhibitors;    -   (e) use with signal transduction inhibitors;    -   (f) use with cisplatin or platinum analogs;    -   (g) use with monofunctional alkylating agents;    -   (h) use with bifunctional alkylating agents;    -   (i) use with alkylating agents that damage DNA at a different        place than does dianhydrogalactitol;    -   (j) use with anti-tubulin agents;    -   (k) use with antimetabolites;    -   (l) use with berberine;    -   (m) use with apigenin;    -   (n) use with amonafide;    -   (o) use with colchicine or analogs;    -   (p) use with genistein;    -   (q) use with etoposide;    -   (r) use with cytarabine;    -   (s) use with camptothecins    -   (t) use with vinca alkaloids;    -   (u) use with 5-fluorouracil;    -   (v) use with curcumin;    -   (w) use with NF-κB inhibitors;    -   (x) use with rosmarinic acid;    -   (y) use with mitoguazone;    -   (z) use with tetrandrine;    -   (aa) use with temozolomide;    -   (ab) use with VEGF inhibitors;    -   (ac) use with cancer vaccines;    -   (ad) use with EGFR inhibitors;    -   (ae) use with tyrosine kinase inhibitors; and    -   (af) use with poly (ADP-ribose) polymerase (PARP) inhibitors.

Topoisomerase inhibitors include, but are not limited to, irinotecan,topotecan, camptothecin, lamellarin D, amsacrine, etoposide, etoposidephosphate, teniposide, doxorubicin, and ICRF-193.

Fraudulent nucleosides include, but are not limited to, cytosinearabinoside, gemcitabine, and fludarabine; other fraudulent nucleosidesare known in the art.

Fraudulent nucleotides include, but are not limited to, tenofovirdisoproxil fumarate and adefovir dipivoxil; other fraudulent nucleotidesare known in the art.

Thymidylate synthetase inhibitors include, but are not limited to,raltitrexed, pemetrexed, nolatrexed, ZD9331, GS7094L, fluorouracil, andBGC 945.

Signal transduction inhibitors are described in A. V. Lee et al., “NewMechanisms of Signal Transduction Inhibitor Action: Receptor TyrosineKinase Down-Regulation and Blockade of Signal Transactivation,” Clin.Cancer Res. 9: 516s (2003), incorporated herein in its entirety by thisreference.

Alkylating agents include, but are not limited to, Shionogi 254-S,aldo-phosphamide analogues, altretamine, anaxirone, Boehringer MannheimBBR-2207, bendamustine, bestrabucil, budotitane, Wakunaga CA-102,carboplatin, carmustine (BCNU), Chinoin-139, Chinoin-153, chlorambucil,cisplatin, cyclophosphamide, American Cyanamid CL-286558, Sanofi CY-233,cyplatate, Degussa D-19-384, Sumimoto DACHP(Myr)₂, diphenylspiromustine,diplatinum cytostatic, Erba distamycin derivatives, Chugai DWA-2114R,ITI E09, elmustine, Erbamont FCE-24517, estramustine phosphate sodium,fotemustine, Unimed G-6-M, Chinoin GYKI-17230, hepsul-fam, ifosfamide,iproplatin, lomustine (CCNU), mafosfamide, melphalan, mitolactol,nimustine (ACNU), Nippon Kayaku NK-121, NCI NSC-264395, NCI NSC-342215,oxaliplatin, Upjohn PCNU, prednimustine, Proter PTT-119, ranimustine,semustine, SmithKline SK&F-101772, Yakult Honsha SN-22, spiromustine,Tanabe Seiyaku TA-077, tauromustine, temozolomide, teroxirone,tetraplatin and trimelamol, as described in U.S. Pat. No. 7,446,122 byChao et al., incorporated herein by this reference. Specifically, fortreatment of glioblastoma multiforme, alkylating agents such astemozolomide, BCNU, CCNU, and ACNU can be used; these alkylating agentsall damage DNA at O⁶ of guanine, whereas DAG cross-links at N⁷); onealternative is therefore to use DAG in combination with an alkylatingagent that damages DNA at a different place than DAG. The alkylatingagent can be a monofunctional alkylating agent or a bifunctionalalkylating agent. Monofunctional alkylating agents include, but are notlimited to, carmustine lomustine, temozolomide, and dacarbazine, asdescribed in N. Kondo et al., “DNA Damage Induced by Alkylating Agentsand Repair Pathways,” J. Nucl. Acids doi:10.4061/2010/543531 (2010),incorporated herein by this reference; monofunctional alkylating agentsalso include such agents as methyl methanesulfonate,ethylmethanesulfonate, and N-methyl-N-nitrosoguanidine, as described inJ. M. Walling & I. J. Stratford, “Chemosensitization by MonofunctionalAlkylating Agents,” Int. J. Radiat. Oncol. Biol. Phys. 12: 1397-1400(1986), incorporated herein by this reference. Bifunctional alkylatingagents include, but are not limited to, mechlorethamine, chlorambucil,cyclophosphamide, busulfan, nimustine, carmustine, lomustine,fotemustine, and bis-(2-chloroethyl) sulfide (N. Kondo et al. (2010),supra). One significant class of bifunctional alkylating agents includesalkylating agents that target O⁶ of guanine in DNA.

Anti-tubulin agents include, but are not limited to, vinca alkaloids,taxanes, podophyllotoxin, halichondrin B, and homohalichondrin B.

Antimetabolites include, but are not limited to: methotrexate,pemetrexed, 5-fluorouracil, capecitabine, cytarabine, gemcitabine,6-mercaptopurine, and pentostatin, alanosine, AG2037 (Pfizer),5-FU-fibrinogen, acanthifolic acid, aminothiadiazole, brequinar sodium,carmofur, Ciba-Geigy CGP-30694, cyclopentyl cytosine, cytarabinephosphate stearate, cytarabine conjugates, Lilly DATHF, Merrill-DowDDFC, deazaguanine, dideoxycytidine, dideoxyguanosine, didox, YoshitomiDMDC, doxifluridine, Wellcome EHNA, Merck & Co. EX-015, fazarabine,floxuridine, fludarabine phosphate, N-(2′-furanidyl)-5-fluorouracil,Daiichi Seiyaku FO-152, isopropyl pyrrolizine, Lilly LY-188011, LillyLY-264618, methobenzaprim, methotrexate, Wellcome MZPES, norspermidine,NCI NSC-127716, NCI NSC-264880, NCI NSC-39661, NCI NSC-612567,Warner-Lambert PALA, piritrexim, plicamycin, Asahi Chemical PL-AC,Takeda TAC-788, thioguanine, tiazofurin, Erbamont TIF, trimetrexate,tyrosine kinase inhibitors, tyrosine protein kinase inhibitors, TaihoUFT and uricytin.

Berberine has antibiotic activity and prevents and suppresses theexpression of pro-inflammatory cytokines and E-selectin, as well asincreasing adiponectin expression.

Apigenin is a flavone that can reverse the adverse effects ofcyclosporine and has chemoprotective activity, either alone orderivatized with a sugar.

Amonafide is a topoisomerase inhibitor and DNA intercalator that hasanti-neoplastic activity.

Curcumin is believed to have anti-neoplastic, anti-inflammatory,antioxidant, anti-ischemic, anti-arthritic, and anti-amyloid propertiesand also has hepatoprotective activity.

NF-κB inhibitors include, but are not limited to, bortezomib.

Rosmarinic acid is a naturally-occurring phenolic antioxidant that alsohas anti-inflammatory activity.

Mitoguazone is an inhibitor of polyamine biosynthesis throughcompetitive inhibition of S-adenosylmethionine decarboxylase.

Tetrandrine has the chemical structure6,6′,7,12-tetramethoxy-2,2′-dimethyl-1β-berbaman and is a calciumchannel blocker that has anti-inflammatory, immunologic, andantiallergenic effects, as well as an anti-arrhythmic effect similar tothat of quinidine. It has been isolated from Stephania tetranda andother Asian herbs.

VEGF inhibitors include bevacizumab (Avastin), which is a monoclonalantibody against VEGF, itraconazole, and suramin, as well as batimastatand marimastat, which are matrix metalloproteinase inhibitors, andcannabinoids and derivatives thereof.

Cancer vaccines are being developed. Typically, cancer vaccines arebased on an immune response to a protein or proteins occurring in cancercells that does not occur in normal cells. Cancer vaccines includeProvenge for metastatic hormone-refractory prostate cancer, Oncophagefor kidney cancer, CimaVax-EGF for lung cancer, MOBILAN, Neuvenge forHer2/neu expressing cancers such as breast cancer, colon cancer, bladdercancer, and ovarian cancer, Stimuvax for breast cancer, and others.Cancer vaccines are described in S. Pejawar-Gaddy & 0. Finn, “CancerVaccines: Accomplishments and Challenges,” Crit. Rev. Oncol. Hematol.67: 93-102 (2008), incorporated herein by this reference.

The epidermal growth factor receptor (EGFR) exists on the cell surfaceof mammalian cells and is activated by binding of the receptor to itsspecific ligands, including, but not limited to epidermal growth factorand transforming growth factor α. Upon activation by binding to itsgrowth factor ligands, EGFR undergoes a transition from an inactivemonomeric form to an active homodimer, although preformed active dimersmay exist before ligand binding. In addition to forming activehomodimers after ligand binding, EGFR may pair with another member ofthe ErbB receptor family, such as ErbB2/Her2/neu, to create an activatedheterodimer. There is also evidence that clusters of activated EGFRsform, although it is uncertain whether such clustering is important foractivation itself or occurs subsequent to activation of individualdimers. EGFR dimerization stimulates its intracellular intrinsicprotein-tyrosine kinase activity. As a result, autophosphorylation ofseveral tyrosine residues in the carboxyl-terminal domain of EGFRoccurs. These residues include Y992, Y1045, Y1068, Y1148, and Y1171.Such autophosphorylation elicits downstream activation and signaling byseveral other proteins that associate with the phosphorylated tyrosineresidues through their own phosphotyrosine-binding SH2 domains. Thesignaling of these proteins that associate with the phosphorylatedtyrosine residues through their own phosphotyrosine-binding SH2 domainscan then initiate several signal transduction cascades and lead to DNAsynthesis and cell proliferation. The kinase domain of EGFR can alsocross-phosphorylate tyrosine residues of other receptors that it isaggregated with, and can itself be activated in that manner. EGFR isencoded by the c-erbB1 proto-oncogene and has a molecular mass of 170kDa. It is a transmembrane glycoprotein with a cysteine-richextracellular region, an intracellular domain containing anuninterrupted tyrosine kinase site, and multiple autophosphorylationsites clustered at the carboxyl-terminal tail as described above. Theextracellular portion has been subdivided into four domains: domains Iand III, which have 37% sequence identity, are cysteine-poor andconformationally contain the site for ligand (EGF and transforminggrowing factor α (TGFα) binding. Cysteine-rich domains II and IV containN-linked glycosylation sites and disulfide bonds, which determine thetertiary conformation of the external domain of the protein molecule. Inmany human cell lines, TGFα expression has a strong correlation withEGFR overexpression, and therefore TGFα was considered to act in anautocrine manner, stimulating proliferation of the cells in which it isproduced via activation of EGFR. Binding of a stimulatory ligand to theEGFR extracellular domain results in receptor dimerization andinitiation of intracellular signal transduction, the first step of whichis activation of the tyrosine kinase. The earliest consequence of kinaseactivation is the phosphorylation of its own tyrosine residues(autophosphorylation) as described above. This is followed byassociation with activation of signal transducers leading tomitogenesis. Mutations that lead to EGFR expression or overactivity havebeen associated with a number of malignancies, including glioblastomamultiforme. A specific mutation of EGFR known as EGFR Variant III hasfrequently been observed in glioblastoma (C. T. Kuan et al., “EGF MutantReceptor VIII as a Molecular Target in Cancer Therapy,” Endocr. Relat.Cancer 8: 83-96 (2001), incorporated herein by this reference). EGFR isconsidered an oncogene. Inhibitors of EGFR include, but are not limitedto, erlotinib, gefitinib, lapatinib, lapatinib ditosylate, afatinib,canertinib, neratinib, CP-724714, WHI-P154, TAK-285, AST-1306,ARRY-334543, ARRY-380, AG-1478, tyrphostin 9, dacomitinib,desmethylerlotinib, OSI-420, AZD8931, AEE788, pelitinib, CUDC-101,WZ8040, WZ4002, WZ3146, AG-490, XL647, PD153035 HCl, BMS-599626, BIBW2992, CI 1033, CP 724714, OSI 420, and vandetinib. Particularlypreferred EGFR inhibitors include erlotinib, afatinib, and lapatinib.

Tyrosine kinase inhibitors include, but are not limited to, imatinib,gefitinib, erlotinib, sunitinib, sorafenib, foretinib, cederinib,axitinib, carbozantinib, BIBF1120, golvatinib, dovitinib, ZM 306416, ZM323881 HCl, SAR 131675, semaxinib, telatinib, pazopanib, ponatinib,crenolanib, tivanitib, mubritinib, danusertib, brivanib, fingolimod,saracatinib, rebastinib, quizartinib, tandutinib, amuvatinib, ibrutinib,fostamatinib, crizotinib, and linsitinib. Such tyrosine kinaseinhibitors can inhibit tyrosine kinases associated with one or more ofthe following receptors: VEGFR, EGFR, PDGFR, c-Kit, c-Met, Her-2, FGFR,FLT-3, IGF-1R, ALK, c-RET, and Tie-2. As the activity of epidermalgrowth factor receptor (EGFR) involves the activity of a tyrosinekinase, the category of tyrosine kinase inhibitors overlaps with thecategory of EGFR inhibitors. A number of tyrosine kinase inhibitorsinhibit the activity of both EGFR and at least one other tyrosinekinase. In general, tyrosine kinase inhibitors can operate by fourdifferent mechanisms: competition with adenosine triphosphate (ATP),used by the tyrosine kinase to carry out the phosphorylation reaction;competition with the substrate; competition with both ATP and thesubstrate; or allosteric inhibition. The activity of these inhibitors isdisclosed in P. Yaish et al., “Blocking of EGF-Dependent CellProliferation by EGF Receptor Kinase Inhibitors,” Science 242: 933-935(1988); A. Gazit et al., “Tyrphostins. 2. Heterocyclic and α-SubstitutedBenzylidenemalononitrile Tyrphostins as Potent Inhibitors of EGFReceptor and ErbB2/neu Tyrosine Kinases,” J. Med. Chem. 34: 1896-1907(1991); N. Osherov et al., “Selective Inhibition of the Epidermal GrowthFactor and HER2/neu Receptors by Tyrphostins,” J. Biol. Chem. 268:11134-11142 (1993); and A. Levitzki & E. Mishani, “Tyrphostins and OtherTyrosine Kinase Inhibitors,” Annu. Rev. Biochem. 75: 93-109 (2006), allof which are incorporated herein by this reference.

In one alternative, when the drug combination is use with an alkylatingagent, the alkylating agent can be selected from the group consisting ofBCNU, BCNU wafers (Gliadel), ACNU, CCNU, bendamustine (Treanda),lomustine, and temozolimide (Temodar).

When the improvement is made by chemosensitization, thechemosensitization can comprise, but is not limited to, the use of asubstituted hexitol derivative as a chemosensitizer in combination withan agent selected from the group consisting of:

-   -   (a) topoisomerase inhibitors;    -   (b) fraudulent nucleosides;    -   (c) fraudulent nucleotides;    -   (d) thymidylate synthetase inhibitors;    -   (e) signal transduction inhibitors;    -   (f) cisplatin or platinum analogs;    -   (g) alkylating agents;    -   (h) anti-tubulin agents;    -   (i) antimetabolites;    -   (j) berberine;    -   (k) apigenin;    -   (l) amonafide;    -   (m) colchicine or analogs;    -   (n) genistein;    -   (o) etoposide;    -   (p) cytarabine;    -   (q) camptothecins;    -   (r) vinca alkaloids;    -   (s) topoisomerase inhibitors;    -   (t) 5-fluorouracil;    -   (u) curcumin;    -   (v) NF-κB inhibitors;    -   (w) rosmarinic acid;    -   (x) mitoguazone;    -   (y) tetrandrine;    -   (z) a tyrosine kinase inhibitor;    -   (aa) an inhibitor of EGFR; and    -   (ab) an inhibitor of PARP.

When the improvement is made by chemopotentiation, the chemopotentiationcan comprise, but is not limited to, the use of a substituted hexitolderivative as a chemopotentiator in combination with an agent selectedfrom the group consisting of:

-   -   (a) topoisomerase inhibitors;    -   (b) fraudulent nucleosides;    -   (c) fraudulent nucleotides;    -   (d) thymidylate synthetase inhibitors;    -   (e) signal transduction inhibitors;    -   (f) cisplatin or platinum analogs;    -   (g) alkylating agents;    -   (h) anti-tubulin agents;    -   (i) antimetabolites;    -   (j) berberine;    -   (k) apigenin;    -   (l) amonafide;    -   (m) colchicine or analogs;    -   (n) genistein;    -   (o) etoposide;    -   (p) cytarabine;    -   (q) camptothecins;    -   (r) vinca alkaloids;    -   (s) 5-fluorouracil;    -   (t) curcumin;    -   (u) NF-κB inhibitors;    -   (v) rosmarinic acid;    -   (w) mitoguazone;    -   (x) tetrandrine;    -   (y) a tyrosine kinase inhibitor;    -   (z) an inhibitor of EGFR; and    -   (aa) an inhibitor of PARP.

In one alternative, when the chemopotentiation involveschemopotentiation of an alkylating agent by the activity ofdianhydrogalactitol, the alkylating agent can be selected from the groupconsisting of BCNU, BCNU wafers (Gliadel), CCNU, bendamustine (Treanda),lomustine, ACNU, and temozolimide (Temodar).

When the improvement is made by post-treatment management, thepost-treatment management can be, but is not limited to, a methodselected from the group consisting of:

-   -   (a) a therapy associated with pain management;    -   (b) administration of an anti-emetic;    -   (c) an anti-nausea therapy;    -   (d) administration of an anti-inflammatory agent;    -   (e) administration of an anti-pyretic agent; and    -   (f) administration of an immune stimulant.

When the improvement is made by alternative medicine/post-treatmentsupport, the alternative medicine/post-treatment support can be, but isnot limited to, a method selected from the group consisting of:

-   -   (a) hypnosis;    -   (b) acupuncture;    -   (c) meditation;    -   (d) a herbal medication created either synthetically or through        extraction; and    -   (e) applied kinesiology.

In one alternative, when the method is a herbal medication createdeither synthetically or through extraction, the herbal medicationcreated either synthetically or through extraction can be selected fromthe group consisting of:

-   -   (a) a NF-κB inhibitor;    -   (b) a natural anti-inflammatory;    -   (c) an immunostimulant;    -   (d) an antimicrobial; and    -   (e) a flavonoid, isoflavone, or flavone.

When the herbal medication created either synthetically or throughextraction is a NF-κB inhibitor, the NF-κB inhibitor can be selectedfrom the group consisting of parthenolide, curcumin, and rosmarinicacid. When the herbal medication created either synthetically or throughextraction is a natural anti-inflammatory, the natural anti-inflammatorycan be selected from the group consisting of rhein and parthenolide.When the herbal medication created either synthetically or throughextraction is an immunostimulant, the immunostimulant can be a productfound in or isolated from Echinacea. When the herbal medication createdeither synthetically or through extraction is an anti-microbial, theanti-microbial can be berberine. When the herbal medication createdeither synthetically or through extraction is a flavonoid or flavone,the flavonoid, isoflavone, or flavone can be selected from the groupconsisting of apigenin, genistein, apigenenin, genistein, genistin,6″-O-malonylgenistin, 6″-O-acetylgenistin, daidzein, daidzin,6″-O-malonyldaidzin, 6″-O-acetylgenistin, glycitein, glycitin,6″-O-malonylglycitin, and 6-O-acetylglycitin.

When the improvement is made by a bulk drug product improvement, thebulk drug product improvement can be, but is not limited to, a bulk drugproduct improvement selected from the group consisting of:

-   -   (a) salt formation;    -   (b) preparation as a homogeneous crystal structure;    -   (c) preparation as a pure isomer;    -   (d) increased purity;    -   (e) preparation with lower residual solvent content; and    -   (f) preparation with lower residual heavy metal content.

When the improvement is made by use of a diluent, the diluent can be,but is not limited to, a diluent selected from the group consisting of:

-   -   (a) an emulsion;    -   (b) dimethylsulfoxide (DMSO);    -   (c) N-methylformamide (NMF)    -   (d) DMF;    -   (e) ethanol;    -   (f) benzyl alcohol;    -   (g) dextrose-containing water for injection;    -   (h) Cremophor;    -   (i) cyclodextrin; and    -   (j) PEG.

When the improvement is made by use of a solvent system, the solventsystem can be, but is not limited to, a solvent system selected from thegroup consisting of:

-   -   (a) an emulsion;    -   (b) dimethylsulfoxide (DMSO);    -   (c) N-methylformamide (NMF)    -   (d) DMF;    -   (e) ethanol;    -   (f) benzyl alcohol;    -   (g) dextrose-containing water for injection;    -   (h) Cremophor;    -   (i) cyclodextrin; and    -   (j) PEG.

When the improvement is made by use of an excipient, the excipient canbe, but is not limited to, an excipient selected from the groupconsisting of:

-   -   (a) mannitol;    -   (b) albumin;    -   (c) EDTA;    -   (d) sodium bisulfite;    -   (e) benzyl alcohol;    -   (f) a carbonate buffer; and    -   (g) a phosphate buffer.

When the improvement is made by use of a dosage form, the dosage formcan be, but is not limited to, a dosage form selected from the groupconsisting of:

-   -   (a) tablets;    -   (b) capsules;    -   (c) topical gels;    -   (d) topical creams;    -   (e) patches;    -   (f) suppositories; and    -   (g) lyophilized dosage fills.

Formulation of pharmaceutical compositions in tablets, capsules, andtopical gels, topical creams or suppositories is well known in the artand is described, for example, in United States Patent ApplicationPublication No. 2004/0023290 by Griffin et al., incorporated herein bythis reference.

Formulation of pharmaceutical compositions as patches such astransdermal patches is well known in the art and is described, forexample, in U.S. Pat. No. 7,728,042 to Eros et al., incorporated hereinby this reference.

Lyophilized dosage fills are also well known in the art. One generalmethod for the preparation of such lyophilized dosage fills, applicableto dianhydrogalactitol and derivatives thereof and todiacetyldianhydrogalactitol and derivatives thereof, comprises thefollowing steps:

(1) Dissolve the drug in water for injection precooled to below 10° C.Dilute to final volume with cold water for injection to yield a 40 mg/mLsolution.

(2) Filter the bulk solution through an 0.2-μm filter into a receivingcontainer under aseptic conditions. The formulation and filtrationshould be completed in 1 hour.

(3) Fill nominal 1.0 mL filtered solution into sterilized glass vials ina controlled target range under aseptic conditions.

(4) After the filling, all vials are placed with rubber stoppersinserted in the “lyophilization position” and loaded in the prechilledlyophilizer. For the lyophilizer, shelf temperature is set at +5° C. andheld for 1 hour; shelf temperature is then adjusted to −5° C. and heldfor one hour, and the condenser, set to −60° C., turned on.

(5) The vials are then frozen to 30° C. or below and held for no lessthan 3 hours, typically 4 hours.

(6) Vacuum is then turned on, the shelf temperature is adjusted to −5°C., and primary drying is performed for 8 hours; the shelf temperatureis again adjusted to −5° C. and drying is carried out for at least 5hours.

(7) Secondary drying is started after the condenser (set at −60° C.) andvacuum are turned on. In secondary drying, the shelf temperature iscontrolled at +5° C. for 1 to 3 hours, typically 1.5 hours, then at 25°C. for 1 to 3 hours, typically 1.5 hours, and finally at 35-40° C. forat least 5 hours, typically for 9 hours, or until the product iscompletely dried.

(8) Break the vacuum with filtered inert gas (e.g., nitrogen). Stopperthe vials in the lyophilizer.

(9) Vials are removed from the lyophilizer chamber and sealed withaluminum flip-off seals. All vials are visually inspected and labeledwith approved labels.

When the improvement is made by use of dosage kits and packaging, thedosage kits and packaging can be, but are not limited to, dosage kitsand packaging selected from the group consisting of the use of ambervials to protect from light and the use of stoppers with specializedcoatings to improve shelf-life stability.

When the improvement is made by use of a drug delivery system, the drugdelivery system can be, but is not limited to, a drug delivery systemselected from the group consisting of:

-   -   (a) nanocrystals;    -   (b) bioerodible polymers;    -   (c) liposomes;    -   (d) slow release injectable gels; and    -   (e) microspheres.

Nanocrystals are described in U.S. Pat. No. 7,101,576 to Hovey et al.,incorporated herein by this reference.

Bioerodible polymers are described in U.S. Pat. No. 7,318,931 to Okumuet al., incorporated herein by this reference. A bioerodible polymerdecomposes when placed inside an organism, as measured by a decline inthe molecular weight of the polymer over time. Polymer molecular weightscan be determined by a variety of methods including size exclusionchromatography (SEC), and are generally expressed as weight averages ornumber averages. A polymer is bioerodible if, when in phosphate bufferedsaline (PBS) of pH 7.4 and a temperature of 37° C., its weight-averagemolecular weight is reduced by at least 25% over a period of 6 months asmeasured by SEC. Useful bioerodible polymers include polyesters, such aspoly(caprolactone), poly(glycolic acid), poly(lactic acid), andpoly(hydroxybutryate); polyanhydrides, such as poly(adipic anhydride)and poly(maleic anhydride); polydioxanone; polyamines; polyamides;polyurethanes; polyesteramides; polyorthoesters; polyacetals;polyketals; polycarbonates; polyorthocarbonates; polyphosphazenes;poly(malic acid); poly(amino acids); polyvinylpyrrolidone; poly(methylvinyl ether); poly(alkylene oxalate); poly(alkylene succinate);polyhydroxycellulose; chitin; chitosan; and copolymers and mixturesthereof.

Liposomes are well known as drug delivery vehicles. Liposome preparationis described in European Patent Application Publication No. EP 1332755by Weng et al., incorporated herein by this reference.

Slow release injectable gels are known in the art and are described, forexample, in B. Jeong et al., “Drug Release from Biodegradable InjectableThermosensitive Hydrogel of PEG-PLGA-PEG Triblock Copolymers,” J.Controlled Release 63: 155-163 (2000), incorporated herein by thisreference.

The use of microspheres for drug delivery is known in the art and isdescribed, for example, in H. Okada & H. Taguchi, “BiodegradableMicrospheres in Drug Delivery,” Crit. Rev. Ther. Drug Carrier Sys. 12:1-99 (1995), incorporated herein by this reference.

When the improvement is made by use of a drug conjugate form, the drugconjugate form can be, but is not limited to, a drug conjugate formselected from the group consisting of:

-   -   (a) a polymer system;    -   (b) polylactides;    -   (c) polyglycolides;    -   (d) amino acids;    -   (e) peptides; and    -   (f) multivalent linkers.

Polylactide conjugates are well known in the art and are described, forexample, in R. Tong & C. Cheng, “Controlled Synthesis ofCamptothecin-Polylactide Conjugates and Nanoconjugates,” BioconjugateChem. 21: 111-121 (2010), incorporated by this reference.

Polyglycolide conjugates are also well known in the art and aredescribed, for example, in PCT Patent Application Publication No. WO2003/070823 by Elmaleh et al., incorporated herein by this reference.

Multivalent linkers are known in the art and are described, for example,in United States Patent Application Publication No. 2007/0207952 bySilva et al., incorporated herein by this reference. For example,multivalent linkers can contain a thiophilic group for reaction with areactive cysteine, and multiple nucleophilic groups (such as NH or OH)or electrophilic groups (such as activated esters) that permitattachment of a plurality of biologically active moieties to the linker.

Suitable reagents for cross-linking many combinations of functionalgroups are known in the art. For example, electrophilic groups can reactwith many functional groups, including those present in proteins orpolypeptides. Various combinations of reactive amino acids andelectrophiles are known in the art and can be used. For example,N-terminal cysteines, containing thiol groups, can be reacted withhalogens or maleimides. Thiol groups are known to have reactivity with alarge number of coupling agents, such as alkyl halides, haloacetylderivatives, maleimides, aziridines, acryloyl derivatives, arylatingagents such as aryl halides, and others. These are described in G. T.Hermanson, “Bioconjugate Techniques” (Academic Press, San Diego, 1996),pp. 146-150, incorporated herein by this reference. The reactivity ofthe cysteine residues can be optimized by appropriate selection of theneighboring amino acid residues. For example, a histidine residueadjacent to the cysteine residue will increase the reactivity of thecysteine residue. Other combinations of reactive amino acids andelectrophilic reagents are known in the art. For example, maleimides canreact with amino groups, such as the ε-amino group of the side chain oflysine, particularly at higher pH ranges. Aryl halides can also reactwith such amino groups. Haloacetyl derivatives can react with theimidazolyl side chain nitrogens of histidine, the thioether group of theside chain of methionine, and the .epsilon.-amino group of the sidechain of lysine. Many other electrophilic reagents are known that willreact with the ε-amino group of the side chain of lysine, including, butnot limited to, isothiocyanates, isocyanates, acyl azides,N-hydroxysuccinimide esters, sulfonyl chlorides, epoxides, oxiranes,carbonates, imidoesters, carbodiimides, and anhydrides. These aredescribed in G. T. Hermanson, “Bioconjugate Techniques” (Academic Press,San Diego, 1996), pp. 137-146, incorporated herein by this reference.Additionally, electrophilic reagents are known that will react withcarboxylate side chains such as those of aspartate and glutamate, suchas diazoalkanes and diazoacetyl compounds, carbonydilmidazole, andcarbodiimides. These are described in G. T. Hermanson, “BioconjugateTechniques” (Academic Press, San Diego, 1996), pp. 152-154, incorporatedherein by this reference. Furthermore, electrophilic reagents are knownthat will react with hydroxyl groups such as those in the side chains ofserine and threonine, including reactive haloalkane derivatives. Theseare described in G. T. Hermanson, “Bioconjugate Techniques” (AcademicPress, San Diego, 1996), pp. 154-158, incorporated herein by thisreference. In another alternative embodiment, the relative positions ofelectrophile and nucleophile (i.e., a molecule reactive with anelectrophile) are reversed so that the protein has an amino acid residuewith an electrophilic group that is reactive with a nucleophile and thetargeting molecule includes therein a nucleophilic group. This includesthe reaction of aldehydes (the electrophile) with hydroxylamine (thenucleophile), described above, but is more general than that reaction;other groups can be used as electrophile and nucleophile. Suitablegroups are well known in organic chemistry and need not be describedfurther in detail.

Additional combinations of reactive groups for cross-linking are knownin the art. For example, amino groups can be reacted withisothiocyanates, isocyanates, acyl azides, N-hydroxysuccinimide (NHS)esters, sulfonyl chlorides, aldehydes, glyoxals, epoxides, oxiranes,carbonates, alkylating agents, imidoesters, carbodiimides, andanhydrides. Thiol groups can be reacted with haloacetyl or alkyl halidederivatives, maleimides, aziridines, acryloyl derivatives, acylatingagents, or other thiol groups by way of oxidation and the formation ofmixed disulfides. Carboxy groups can be reacted with diazoalkanes,diazoacetyl compounds, carbonyldiimidazole, carbodiimides. Hydroxylgroups can be reacted with epoxides, oxiranes, carbonyldiimidazole,N,N′-disuccinimidyl carbonate, N-hydroxysuccinimidyl chloroformate,periodate (for oxidation), alkyl halogens, or isocyanates. Aldehyde andketone groups can react with hydrazines, reagents forming Schiff bases,and other groups in reductive amination reactions or Mannichcondensation reactions. Still other reactions suitable for cross-linkingreactions are known in the art. Such cross-linking reagents andreactions are described in G. T. Hermanson, “Bioconjugate Techniques”(Academic Press, San Diego, 1996), incorporated herein by thisreference.

When the improvement is made by use of a prodrug system, the prodrugsystem can be, but is not limited to, a prodrug system selected from thegroup consisting of:

-   -   (a) the use of enzyme sensitive esters;    -   (b) the use of dimers;    -   (c) the use of Schiff bases;    -   (d) the use of pyridoxal complexes; and    -   (e) the use of caffeine complexes.

The use of prodrug systems is described in T. Jarvinen et al., “Designand Pharmaceutical Applications of Prodrugs” in Drug Discovery Handbook(S. C. Gad, ed., Wiley-Interscience, Hoboken, N.J., 2005), ch. 17, pp.733-796, incorporated herein by this reference. This publicationdescribes the use of enzyme sensitive esters as prodrugs. The use ofdimers as prodrugs is described in U.S. Pat. No. 7,879,896 to Allegrettiet al., incorporated herein by this reference. The use of peptides inprodrugs is described in S. Prasad et al., “Delivering MultipleAnticancer Peptides as a Single Prodrug Using Lysyl-Lysine as a FacileLinker,” J. Peptide Sci. 13: 458-467 (2007), incorporated herein by thisreference. The use of Schiff bases as prodrugs is described in U.S. Pat.No. 7,619,005 to Epstein et al., incorporated herein by this reference.The use of caffeine complexes as prodrugs is described in U.S. Pat. No.6,443,898 to Unger et al., incorporated herein by this reference.

When the improvement is made by use of a multiple drug system, themultiple drug system can be, but is not limited to, a multiple drugsystem selected from the group consisting of:

-   -   (a) use of multi-drug resistance inhibitors;    -   (b) use of specific drug resistance inhibitors;    -   (c) use of specific inhibitors of selective enzymes;    -   (d) use of signal transduction inhibitors;    -   (e) use of repair inhibition; and    -   (f) use of topoisomerase inhibitors with non-overlapping side        effects.

Multi-drug resistance inhibitors are described in U.S. Pat. No.6,011,069 to Inomata et al., incorporated herein by this reference.

Specific drug resistance inhibitors are described in T. Hideshima etal., “The Proteasome Inhibitor PS-341 Inhibits Growth, InducesApoptosis, and Overcomes Drug Resistance in Human Multiple MyelomaCells,” Cancer Res. 61: 3071-3076 (2001), incorporated herein by thisreference.

Repair inhibition is described in N. M. Martin, “DNA Repair Inhibitionand Cancer Therapy,” J. Photochem. Photobiol. B 63: 162-170 (2001),incorporated herein by this reference.

When the improvement is made by biotherapeutic enhancement, thebiotherapeutic enhancement can be performed by use in combination assensitizers/potentiators with a therapeutic agent or technique that canbe, but is not limited to, a therapeutic agent or technique selectedfrom the group consisting of:

-   -   (a) cytokines;    -   (b) lymphokines;    -   (c) therapeutic antibodies;    -   (d) antisense therapies;    -   (e) gene therapies;    -   (f) ribozymes;    -   (g) RNA interference; and    -   (h) vaccines.

Antisense therapies are described, for example, in B. Weiss et al.,“Antisense RNA Gene Therapy for Studying and Modulating BiologicalProcesses,” Cell. Mol. Life Sci. 55: 334-358 (1999), incorporated hereinby this reference.

Ribozymes are described, for example, in S. Pascolo, “RNA-BasedTherapies” in Drug Discovery Handbook (S. C. Gad, ed.,Wiley-Interscience, Hoboken, N.J., 2005), ch. 27, pp. 1273-1278,incorporated herein by this reference.

RNA interference is described, for example, in S. Pascolo, “RNA-BasedTherapies” in Drug Discovery Handbook (S. C. Gad, ed.,Wiley-Interscience, Hoboken, N.J., 2005), ch. 27, pp. 1278-1283,incorporated herein by this reference.

As described above, typically, cancer vaccines are based on an immuneresponse to a protein or proteins occurring in cancer cells that doesnot occur in normal cells. Cancer vaccines include Provenge formetastatic hormone-refractory prostate cancer, Oncophage for kidneycancer, CimaVax-EGF for lung cancer, MOBILAN, Neuvenge for Her2/neuexpressing cancers such as breast cancer, colon cancer, bladder cancer,and ovarian cancer, Stimuvax for breast cancer, and others. Cancervaccines are described in S. Pejawar-Gaddy & 0. Finn, (2008), supra.

When the biotherapeutic enhancement is use in combination assensitizers/potentiators with a therapeutic antibody, the therapeuticantibody can be, but is not limited to, a therapeutic antibody selectedfrom the group consisting of bevacizumab (Avastin), rituximab (Rituxan),trastuzumab (Herceptin), and cetuximab (Erbitux).

When the improvement is made by use of biotherapeutic resistancemodulation, the biotherapeutic resistance modulation can be, but is notlimited to, use against glioblastoma multiforme tumors resistant to atherapeutic agent or technique selected from the group consisting of:

-   -   (a) biological response modifiers;    -   (b) cytokines;    -   (c) lymphokines;    -   (d) therapeutic antibodies;    -   (e) antisense therapies;    -   (f) gene therapies;    -   (g) ribozymes;    -   (h) RNA interference; and    -   (i) vaccines.

When the biotherapeutic resistance modulation is use against tumorsresistant to therapeutic antibodies, the therapeutic antibody can be,but is not limited to, a therapeutic antibody selected from the groupconsisting of bevacizumab (Avastin), rituximab (Rituxan), trastuzumab(Herceptin), and cetuximab (Erbitux).

When the improvement is made by radiation therapy enhancement, theradiation therapy enhancement can be, but is not limited to, a radiationtherapy enhancement agent or technique selected from the groupconsisting of:

-   -   (a) hypoxic cell sensitizers;    -   (b) radiation sensitizers/protectors;    -   (c) photosensitizers;    -   (d) radiation repair inhibitors;    -   (e) thiol depleters;    -   (f) vaso-targeted agents;    -   (g) DNA repair inhibitors;    -   (h) radioactive seeds;    -   (i) radionuclides;    -   (j) radiolabeled antibodies; and    -   (k) brachytherapy.

A substituted hexitol derivative such as dianhydrogalactitol can be usedin combination with radiation for the treatment of glioblastomamultiforme.

Hypoxic cell sensitizers are described in C. C. Ling et al., “The Effectof Hypoxic Cell Sensitizers at Different Irradiation Dose Rates,”Radiation Res. 109: 396-406 (1987), incorporated herein by thisreference. Radiation sensitizers are described in T. S. Lawrence,“Radiation Sensitizers and Targeted Therapies,” Oncology 17 (Suppl. 13)23-28 (2003), incorporated herein by this reference. Radiationprotectors are described in S. B. Vuyyuri et al., “Evaluation ofD-Methionine as a Novel Oral Radiation Protector for Prevention ofMucositis,” Clin. Cancer Res. 14: 2161-2170 (2008), incorporated hereinby this reference. Photosensitizers are described in R. R. Allison & C.H. Sibata, “Oncologic Photodynamic Therapy Photosensitizers: A ClinicalReview,” Photodiagnosis Photodynamic Ther. 7: 61-75 (2010), incorporatedherein by this reference. Radiation repair inhibitors and DNA repairinhibitors are described in M. Hingorani et al., “Evaluation of Repairof Radiation-Induced DNA Damage Enhances Expression fromReplication-Defective Adenoviral Vectors,” Cancer Res. 68: 9771-9778(2008), incorporated herein by this reference. Thiol depleters aredescribed in K. D. Held et al., “Postirradiation Sensitization ofMammalian Cells by the Thiol-Depleting Agent Dimethyl Fumarate,”Radiation Res. 127: 75-80 (1991), incorporated herein by this reference.Vaso-targeted agents are described in A. L. Seynhaeve et al., “TumorNecrosis Factor α Mediates Homogeneous Distribution of Liposomes inMurine Melanoma that Contributes to a Better Tumor Response,” CancerRes. 67: 9455-9462 (2007). As described above, radiation therapy isfrequently employed for the treatment of GBM, so radiation therapyenhancement is significant for this malignancy.

When the improvement is by use of a novel mechanism of action, the novelmechanism of action can be, but is not limited to, a novel mechanism ofaction that is a therapeutic interaction with a target or mechanismselected from the group consisting of:

-   -   (a) inhibitors of poly-ADP ribose polymerase;    -   (b) agents that affect vasculature or vasodilation;    -   (c) oncogenic targeted agents;    -   (d) signal transduction inhibitors;    -   (e) EGFR inhibition;    -   (f) protein kinase C inhibition;    -   (g) phospholipase C downregulation;    -   (h) Jun downregulation;    -   (i) histone genes;    -   (j) VEGF;    -   (k) ornithine decarboxylase;    -   (l) ubiquitin C;    -   (m) Jun D;    -   (n) v-Jun;    -   (o) GPCRs;    -   (p) protein kinase A;    -   (q) protein kinases other than protein kinase A;    -   (r) prostate specific genes;    -   (s) telomerase;    -   (t) histone deacetylase; and    -   (u) tyrosine kinase inhibitors.

EGFR inhibition is described in G. Giaccone & J. A. Rodriguez, “EGFRInhibitors: What Have We Learned from the Treatment of Lung Cancer,”Nat. Clin. Pract. Oncol. 11: 554-561 (2005), incorporated herein by thisreference. Protein kinase C inhibition is described in H. C. Swannie &S. B. Kaye, “Protein Kinase C Inhibitors,” Curr. Oncol. Rep. 4: 37-46(2002), incorporated herein by this reference. Phospholipase Cdownregulation is described in A. M. Martelli et al., “PhosphoinositideSignaling in Nuclei of Friend Cells: Phospholipase C β Downregulation IsRelated to Cell Differentiation,” Cancer Res. 54: 2536-2540 (1994),incorporated herein by this reference. Downregulation of Jun(specifically, c-Jun) is described in A. A. P. Zada et al.,“Downregulation of c-Jun Expression and Cell Cycle Regulatory Moleculesin Acute Myeloid Leukemia Cells Upon CD44 Ligation,” Oncogene 22:2296-2308 (2003), incorporated herein by this reference. The role ofhistone genes as a target for therapeutic intervention is described inB. Calabretta et al., “Altered Expression of G1-Specific Genes in HumanMalignant Myeloid Cells,” Proc. Natl. Acad. Sci. USA 83: 1495-1498(1986). The role of VEGF as a target for therapeutic intervention isdescribed in A. Zielke et al., “VEGF-Mediated Angiogenesis of HumanPheochromocytomas Is Associated to Malignancy and Inhibited by anti-VEGFAntibodies in Experimental Tumors,” Surgery 132: 1056-1063 (2002),incorporated herein by this reference. The role of ornithinedecarboxylase as a target for therapeutic intervention is described inJ. A. Nilsson et al., “Targeting Ornithine Decarboxylase in Myc-InducedLymphomagenesis Prevents Tumor Formation,” Cancer Cell 7: 433-444(2005), incorporated herein by this reference. The role of ubiquitin Cas a target for therapeutic intervention is described in C. Aghajanianet al., “A Phase I Trial of the Novel Proteasome Inhibitor PS341 inAdvanced Solid Tumor Malignancies,” Clin. Cancer Res. 8: 2505-2511(2002), incorporated herein by this reference. The role of Jun D as atarget for therapeutic intervention is described in M. M. Caffarel etal., “JunD Is Involved in the Antiproliferative Effect ofΔ⁹-Tetrahydrocannibinol on Human Breast Cancer Cells,” Oncogene 27:5033-5044 (2008), incorporated herein by this reference. The role ofv-Jun as a target for therapeutic intervention is described in M. Gao etal., “Differential and Antagonistic Effects of v-Jun and c-Jun,” CancerRes. 56: 4229-4235 (1996), incorporated herein by this reference. Therole of protein kinase A as a target for therapeutic intervention isdescribed in P. C. Gordge et al., “Elevation of Protein Kinase A andProtein Kinase C in Malignant as Compared With Normal Breast Tissue,”Eur. J. Cancer 12: 2120-2126 (1996), incorporated herein by thisreference. The role of telomerase as a target for therapeuticintervention is described in E. K. Parkinson et al., “Telomerase as aNovel and Potentially Selective Target for Cancer Chemotherapy,” Ann.Med. 35: 466-475 (2003), incorporated herein by this reference. The roleof histone deacetylase as a target for therapeutic intervention isdescribed in A. Melnick & J. D. Licht, “Histone Deacetylases asTherapeutic Targets in Hematologic Malignancies,” Curr. Opin. Hematol.9: 322-332 (2002), incorporated herein by this reference.

When the improvement is made by use of selective target cell populationtherapeutics, the use of selective target cell population therapeuticscan be, but is not limited to, a use selected from the group consistingof:

-   -   (a) use against radiation sensitive cells;    -   (b) use against radiation resistant cells; and    -   (c) use against energy depleted cells.

The improvement can also be made by use of dianhydrogalactitol incombination with ionizing radiation.

When the improvement is made by use of an agent that counteractsmyelosuppression, the agent that counteracts myelosuppression can be,but is not limited to, a dithiocarbamate.

U.S. Pat. No. 5,035,878 to Borch et al., incorporated herein by thisreference, discloses dithiocarbamates for treatment of myelosuppression;the dithiocarbamates are compounds of the formula R¹R²NCS(S)M orR¹R²NCSS—SC(S)NR³R⁴, wherein R¹, R², R³, and R⁴ are the same ordifferent, and R¹, R², R³, and R⁴ are aliphatic, cycloaliphatic, orheterocycloaliphatic groups that are unsubstituted or substituted byhydroxyl; or wherein one of R¹ and R² and one of R³ and R⁴ can behydrogen; or wherein R¹, R², R³, and R⁴ taken together with the nitrogenatom upon which the pair of R groups is substituted, can be a 5-memberedor 6-membered N-heterocyclic ring which is aliphatic or aliphaticinterrupted by a ring oxygen or a second ring nitrogen, and M ishydrogen or one equivalent or a pharmaceutically acceptable cation, inwhich case the rest of the molecule is negatively charged.

U.S. Pat. No. 5,294,430 to Borch et al., incorporated herein by thisreference, discloses additional dithiocarbamates for treatment ofmyelosuppression. In general, these are compounds of Formula (D-I):

wherein:

(i) R¹ and R² are the same or different C₁-C₆ alkyl groups, C₃-C₆cycloalkyl groups, or C₅-C₆ heterocycloalkyl groups; or

(ii) one of R¹ and R², but not both, can be H; or

(iii) R¹ and R² taken together with the nitrogen atom can be a5-membered or 6-membered N-heterocyclic ring which is aliphatic oraliphatic interrupted by a ring oxygen or a second ring nitrogen; and

(iv) M is hydrogen or one equivalent of a pharmaceutically acceptablecation, in which case the rest of the molecule is negatively charged; or

(v) M is a moiety of Formula (D-II):

wherein R³ and R⁴ are defined in the same manner as R¹ and R². Where thegroup defined by Formula (D-I) is an anion, the cation can be anammonium cation or can be derived from a monovalent or divalent metalsuch as an alkali metal or an alkaline earth metal, such as Na⁺, K⁺, orZn⁺². In the case of the dithiocarbamic acids, the group defined byFormula (D-I) is linked to an ionizable hydrogen atom; typically, thehydrogen atom will dissociate at a pH above about 5.0. Amongdithiocarbamates that can be used are: N-methyl,N-ethyldithiocarbamates,hexamethylenedithiocarbamic acid, sodiumdi(β-hydroxyethyl)dithiocarbamate, various dipropyl, dibutyl and diamyldithiocarbamates, sodium N-methyl,N-cyclobutylmethyl dithiocarbamate,sodium N-allyl-N-cyclopropylmethyldithiocarbamate,cyclohexylamyldithiocarbamates, dibenzyl-dithiocarbamates, sodiumdimethylene-dithiocarbamate, various pentamethylene dithiocarbamatesalts, sodium pyrrolidine-N-carbodithioate, sodiumpiperidine-N-carbodithioate, sodium morpholine-N-carbo-dithioate,α-furfuryl dithiocarbamates and imidazoline dithiocarbamates. Anotheralternative is a compound where R¹ of Formula (D-I) is ahydroxy-substituted or, preferably, a (bis to penta)polyhydroxy-substituted lower alkyl group having up to 6 carbon atoms.For example, R¹ can be HO—CH₂—CHOH—CHOH—CHOH—CHOH—CH₂—. In suchcompounds, R² can be H or lower alkyl (unsubstituted or substituted withone or more hydroxyl groups). Steric problems can be minimized when R²is H, methyl, or ethyl. Accordingly, a particularly preferred compoundof this type is an N-methyl-glucamine dithiocarbamate salt, the mostpreferred cations of these salts being sodium or potassium. Otherpreferred dithiocarbamates include the alkali or alkaline earth metalsalts wherein the anion is di-n-butyldithiocarbamate,di-n-propyldithiocarbamate, pentamethylenedithiocarbamate, ortetramethylene dithiocarbamate.

When the improvement is made by use with an agent that increases theability of the substituted hexitol to pass through the blood-brainbarrier, the agent that increases the ability of the substituted hexitolto pass through the blood-brain barrier can be, but is not limited to:

-   -   (a) a chimeric peptide of the structure of Formula (D-III):

wherein: (A) A is somatostatin, thyrotropin releasing hormone (TRH),vasopressin, alpha interferon, endorphin, muramyl dipeptide or ACTH 4-9analogue; and (B) B is insulin, IGF-I, IGF-II, transferrin, cationized(basic) albumin or prolactin; or a chimeric peptide of the structure ofFormula (D-III) wherein the disulfide conjugating bridge between A and Bis replaced with a bridge of Subformula (D-III(a)):

A-NH(CH₂)₂S—S—B (cleavable linkage)  (D-III(a)),

wherein the bridge is formed using cysteamine and EDAC as the bridgereagents; or a chimeric peptide of the structure of Formula (D-III)wherein the disulfide conjugating bridge between A and B is replacedwith a bridge of Subformula (D-III(b)):

A-NH═CH(CH₂)₃CH═NH—B (non-cleavable linkage)  (D-III(b)),

wherein the bridge is formed using glutaraldehyde as the bridge reagent;

-   -   (b) a composition comprising either avidin or an avidin fusion        protein bonded to a biotinylated substituted hexitol derivative        to form an avidin-biotin-agent complex including therein a        protein selected from the group consisting of insulin,        transferrin, an anti-receptor monoclonal antibody, a cationized        protein, and a lectin;    -   (c) a neutral liposome that is pegylated and incorporates the        substituted hexitol derivative, wherein the polyethylene glycol        strands are conjugated to at least one transportable peptide or        targeting agent;    -   (d) a humanized murine antibody that binds to the human insulin        receptor linked to the substituted hexitol derivative through an        avidin-biotin linkage; and    -   (e) a fusion protein comprising a first segment and a second        segment: the first segment comprising a variable region of an        antibody that recognizes an antigen on the surface of a cell        that after binding to the variable region of the antibody        undergoes antibody-receptor-mediated endocytosis, and,        optionally, further comprises at least one domain of a constant        region of an antibody; and the second segment comprising a        protein domain selected from the group consisting of avidin, an        avidin mutein, a chemically modified avidin derivative,        streptavidin, a streptavidin mutein, and a chemically modified        streptavidin derivative, wherein the fusion protein is linked to        the substituted hexitol by a covalent link to biotin.

Agents that improve penetration of the blood-brain barrier are disclosedin W. M. Pardridge, “The Blood-Brain Barrier: Bottleneck in Brain DrugDevelopment,” NeuroRx 2: 3-14 (2005), incorporated herein by thisreference.

One class of these agents is disclosed in U.S. Pat. No. 4,801,575 toPardridge, incorporated herein by this reference, which discloseschimeric peptides for delivery of agents across the blood-brain barrier.These chimeric peptides include peptides of the general structure ofFormula (D-IV):

wherein:

(i) A is somatostatin, thyrotropin releasing hormone (TRH), vasopressin,alpha interferon, endorphin, muramyl dipeptide or ACTH 4-9 analogue; and

(ii) B is insulin, IGF-I, IGF-II, transferrin, cationized (basic)albumin or prolactin. In another alternative, the disulfide conjugatingbridge between A and B is replaced with a bridge of Subformula(D-IV(a)):

A-NH(CH₂)₂S—S—B (cleavable linkage)  (D-IV(a));

the bridge of Subformula (D-III(a)) is formed when cysteamine and EDACare employed as the bridge reagents. In yet another alternative, thedisulfide conjugating bridge between A and B is replaced with a bridgeof Subformula (D-IV(b)):

A-NH═CH(CH₂)₃═NH—B (non-cleavable linkage)  (D-IV(b));

the bridge of Subformula (D-III(b)) is formed when glutaraldehyde isemployed as the bridge reagent.

U.S. Pat. No. 6,287,792 to Pardridge et al., incorporated herein by thisreference, discloses methods and compositions for delivery of agentsacross the blood-brain barrier comprising either avidin or an avidinfusion protein bonded to a biotinylated agent to form anavidin-biotin-agent complex. The avidin fusion protein can include theamino acid sequences of proteins such as insulin or transferrin, ananti-receptor monoclonal antibody, a cationized protein, or a lectin.

U.S. Pat. No. 6,372,250 to Pardridge, incorporated herein by thisreference, discloses methods and compositions for delivery of agentsacross the blood-brain barrier employing liposomes. The liposomes areneutral liposomes. The surface of the neutral liposomes is pegylated.The polyethylene glycol strands are conjugated to transportable peptidesor other targeting agents. Suitable targeting agents include insulin,transferrin, insulin-like growth factor, or leptin. Alternatively, thesurface of the liposome could be conjugated with 2 differenttransportable peptides, one peptide targeting an endogenous BBB receptorand the other targeting an endogenous BCM (brain cell plasma membrane)peptide. The latter could be specific for particular cells within thebrain, such as neurons, glial cells, pericytes, smooth muscle cells, ormicroglia. Targeting peptides may be endogenous peptide ligands of thereceptors, analogues of the endogenous ligand, or peptidomimetic MAbsthat bind the same receptor of the endogenous ligand. Transferrinreceptor-specific peptidomimetic monoclonal antibodies can be used astransportable peptides. Monoclonal antibodies to the human insulinreceptor can be used as transportable peptides. The conjugation agentswhich are used to conjugate the blood-barrier targeting agents to thesurface of the liposome can be any of the well-known polymericconjugation agents such as sphingomyelin, polyethylene glycol (PEG) orother organic polymers, with PEG preferred. The liposomes preferablyhave diameters of less than 200 nanometers. Liposomes having diametersof between 50 and 150 nanometers are preferred. Especially preferred areliposomes or other nanocontainers having external diameters of about 80nanometers. Suitable types of liposomes are made with neutralphospholipids such as 1-palmitoyl-2-oleoyl-sn-glycerol-3-phosphocholine(POPC), diphosphatidyl phosphocholine,distearoylphosphatidylethanolamine (DSPE), or cholesterol. Thetransportable peptide is linked to the liposome as follows: Atransportable peptide such as insulin or an HIRMAb is thiolated andconjugated to a maleimide group on the tip of a small fraction of thePEG strands; or, surface carboxyl groups on a transportable peptide suchas transferrin or a TfRMAb are conjugated to a hydrazide (Hz) moiety onthe tip of the PEG strand with a carboxyl activator group such asN-methyl-N′-3(dimethylaminopropyl)carbodiimide hydrochloride (EDAC); atransportable peptide is thiolated and conjugated via a disulfide linkerto the liposome that has been reacted with N-succinimidyl3-(2-pyridylthio)propionate (SPDP); or a transportable peptide isconjugated to the surface of the liposome with avidin-biotin technology,e.g., the transportable peptide is mono-biotinylated and is bound toavidin or streptavidin (SA), which is attached to the surface of the PEGstrand.

U.S. Pat. No. 7,388,079 to Pardridge et al., incorporated herein by thisreference, discloses the use of a humanized murine antibody that bindsto the human insulin receptor; the humanized murine antibody can belinked to the agent to be delivered through an avidin-biotin linkage.

U.S. Pat. No. 8,124,095 to Pardridge et al., incorporated herein by thisreference, discloses monoclonal antibodies that are capable of bindingto an endogenous blood-brain barrier receptor-mediated transport systemand are thus capable of serving as a vector for transport of atherapeutic agent across the BBB. The monoclonal antibody can be, forexample, an antibody specifically binding the human insulin receptor onthe human BBB.

United States Patent Application Publication No. 2005/0085419 byMorrison et al., incorporated herein by this reference, discloses afusion protein for delivery of a wide variety of agents to a cell viaantibody-receptor-mediated endocytosis comprises a first segment and asecond segment: the first segment comprising a variable region of anantibody that recognizes an antigen on the surface of a cell that afterbinding to the variable region of the antibody undergoesantibody-receptor-mediated endocytosis, and, optionally, furthercomprises at least one domain of a constant region of an antibody; andthe second segment comprising a protein domain selected from the groupconsisting of avidin, an avidin mutein, a chemically modified avidinderivative, streptavidin, a streptavidin mutein, and a chemicallymodified streptavidin derivative. Typically, the antigen is a protein.Typically, the protein antigen on the surface of the cell is a receptorsuch as a transferrin receptor-or an insulin receptor. The inventionalso includes an antibody construct incorporating the fusion proteinthat is either a heavy chain or a light chain together with acomplementary light chain or heavy chain to form an intact antibodymolecule. The therapeutic agent can be a non-protein molecule and can belinked covalently to biotin.

Another aspect of the present invention is a composition to improve theefficacy and/or reduce the side effects of suboptimally administereddrug therapy employing a substituted hexitol derivative for thetreatment of GBM comprising an alternative selected from the groupconsisting of:

(i) a therapeutically effective quantity of a modified substitutedhexitol derivative or a derivative, analog, or prodrug of a substitutedhexitol derivative or a modified substituted hexitol derivative, whereinthe modified substituted hexitol derivative or the derivative, analog orprodrug of the substituted hexitol derivative or modified substitutedhexitol derivative possesses increased therapeutic efficacy or reducedside effects for treatment of GBM as compared with an unmodifiedsubstituted hexitol derivative;

(ii) a composition comprising:

-   -   (a) a therapeutically effective quantity of a substituted        hexitol derivative, a modified substituted hexitol derivative,        or a derivative, analog, or prodrug of a substituted hexitol        derivative or a modified substituted hexitol derivative; and    -   (b) at least one additional therapeutic agent, therapeutic agent        subject to chemosensitization, therapeutic agent subject to        chemopotentiation, diluent, excipient, solvent system, drug        delivery system, agent to counteract myelosuppression, or agent        that increases the ability of the substituted hexitol to pass        through the blood-brain barrier, wherein the composition        possesses increased therapeutic efficacy or reduced side effects        for treatment of GBM as compared with an unmodified substituted        hexitol derivative;

(iii) a therapeutically effective quantity of a substituted hexitolderivative, a modified substituted hexitol derivative or a derivative,analog, or prodrug of a substituted hexitol derivative or a modifiedsubstituted hexitol derivative that is incorporated into a dosage form,wherein the substituted hexitol derivative, the modified substitutedhexitol derivative or the derivative, analog, or prodrug of asubstituted hexitol derivative or a modified substituted hexitolderivative incorporated into the dosage form possesses increasedtherapeutic efficacy or reduced side effects for treatment of GBM ascompared with an unmodified substituted hexitol derivative;

(iv) a therapeutically effective quantity of a substituted hexitolderivative, a modified substituted hexitol derivative or a derivative,analog, or prodrug of a substituted hexitol derivative or a modifiedsubstituted hexitol derivative that is incorporated into a dosage kitand packaging, wherein the substituted hexitol derivative, the modifiedsubstituted hexitol derivative or the derivative, analog, or prodrug ofa substituted hexitol derivative or a modified substituted hexitolderivative incorporated into the dosage kit and packaging possessesincreased therapeutic efficacy or reduced side effects for treatment ofGBM as compared with an unmodified substituted hexitol derivative; and

(v) a therapeutically effective quantity of a substituted hexitolderivative, a modified substituted hexitol derivative or a derivative,analog, or prodrug of a substituted hexitol derivative or a modifiedsubstituted hexitol derivative that is subjected to a bulk drug productimprovement, wherein substituted hexitol derivative, a modifiedsubstituted hexitol derivative or a derivative, analog, or prodrug of asubstituted hexitol derivative or a modified substituted hexitolderivative subjected to the bulk drug product improvement possessesincreased therapeutic efficacy or reduced side effects for treatment ofGBM as compared with an unmodified substituted hexitol derivative.

As detailed above, typically the unmodified substituted hexitolderivative is selected from the group consisting of dianhydrogalactitol,derivatives of dianhydrogalactitol, diacetyldianhydrogalactitol,derivatives of diacetyldianhydrogalactitol, dibromodulcitol, andderivatives of dibromodulcitol. Preferably, the unmodified substitutedhexitol derivative is dianhydrogalactitol.

In one alternative, the composition comprises a drug combinationcomprising:

(i) a substituted hexitol derivative; and

(ii) an additional therapeutic agent selected from the group consistingof:

-   -   (a) topoisomerase inhibitors;    -   (b) fraudulent nucleosides;    -   (c) fraudulent nucleotides;    -   (d) thymidylate synthetase inhibitors;    -   (e) signal transduction inhibitors;    -   (f) cisplatin or platinum analogs;    -   (g) monofunctional alkylating agents;    -   (h) bifunctional alkylating agents;    -   (i) alkylating agents that damage DNA at a different place than        does dianhydrogalactitol;    -   (j) anti-tubulin agents;    -   (k) antimetabolites;    -   (l) berberine;    -   (m) apigenin;    -   (n) amonafide;    -   (o) colchicine or analogs;    -   (p) genistein;    -   (q) etoposide;    -   (r) cytarabine;    -   (s) camptothecins;    -   (t) vinca alkaloids;    -   (u) 5-fluorouracil;    -   (v) curcumin;    -   (w) NF-κB inhibitors;    -   (x) rosmarinic acid;    -   (y) mitoguazone;    -   (z) tetrandrine;    -   (aa) temozolomide;    -   (ab) VEGF inhibitors;    -   (ac) cancer vaccines;    -   (ad) EGFR inhibitors;    -   (ae) tyrosine kinase inhibitors; and    -   (af) poly (ADP-ribose) polymerase (PARP) inhibitors.

In these alternatives, when the additional therapeutic agent is analkylating agent, the alkylating agent can be, but is not limited to, analkylating agent selected from the group consisting of BCNU, BCNUwafers, CCNU, bendamustine (Treanda), and temozolimide (Temodar).

In another alternative, the composition comprises:

(i) a substituted hexitol derivative; and

(ii) a therapeutic agent subject to chemosensitization selected from thegroup consisting of:

-   -   (a) topoisomerase inhibitors;    -   (b) fraudulent nucleosides;    -   (c) fraudulent nucleotides;    -   (d) thymidylate synthetase inhibitors;    -   (e) signal transduction inhibitors;    -   (f) cisplatin or platinum analogs;    -   (g) alkylating agents;    -   (h) anti-tubulin agents;    -   (i) antimetabolites;    -   (j) berberine;    -   (k) apigenin;    -   (l) amonafide;    -   (m) colchicine or analogs;    -   (n) genistein;    -   (o) etoposide;    -   (p) cytarabine;    -   (q) camptothecins;    -   (r) vinca alkaloids;    -   (s) topoisomerase inhibitors;    -   (t) 5-fluorouracil;    -   (u) curcumin;    -   (v) NF-κB inhibitors;    -   (w) rosmarinic acid;    -   (x) mitoguazone;    -   (y) tetrandrine;    -   (z) a tyrosine kinase inhibitor;    -   (aa) an inhibitor of EGFR; and    -   (ab) an inhibitor of PARP;        wherein the substituted hexitol derivative acts as a        chemosensitizer.

In still another alternative, the composition comprises:

(i) a substituted hexitol derivative; and

(ii) a therapeutic agent subject to chemopotentiation selected from thegroup consisting of:

-   -   (a) topoisomerase inhibitors;    -   (b) fraudulent nucleosides;    -   (c) fraudulent nucleotides;    -   (d) thymidylate synthetase inhibitors;    -   (e) signal transduction inhibitors;    -   (f) cisplatin or platinum analogs;    -   (g) alkylating agents;    -   (h) anti-tubulin agents;    -   (i) antimetabolites;    -   (j) berberine;    -   (k) apigenin;    -   (l) amonafide;    -   (m) colchicine or analogs;    -   (n) genistein;    -   (o) etoposide;    -   (p) cytarabine;    -   (q) camptothecins;    -   (r) vinca alkaloids;    -   (s) 5-fluorouracil;    -   (t) curcumin;    -   (u) NF-κB inhibitors;    -   (v) rosmarinic acid;    -   (w) mitoguazone;    -   (x) tetrandrine;    -   (y) a tyrosine kinase inhibitor;    -   (z) an inhibitor of EGFR; and    -   (aa) an inhibitor of PARP;        wherein the substituted hexitol derivative acts as a        chemopotentiator.

In these alternatives, wherein the additional therapeutic agent is abiotherapeutic, the biotherapeutic can be, but is not limited to, abiotherapeutic selected from the group consisting of Avastin, Herceptin,Rituxan, and Erbitux.

In yet another alternative, the substituted hexitol derivative issubjected to a bulk drug product improvement, wherein the bulk drugproduct improvement is selected from the group consisting of:

-   -   (a) salt formation;    -   (b) preparation as a homogeneous crystal structure;    -   (c) preparation as a pure isomer;    -   (d) increased purity;    -   (e) preparation with lower residual solvent content; and    -   (f) preparation with lower residual heavy metal content.

In still another alternative, the composition comprises a substitutedhexitol derivative and a diluent, wherein the diluent is selected fromthe group consisting of:

-   -   (a) an emulsion;    -   (b) dimethylsulfoxide (DMSO);    -   (c) N-methylformamide (NMF)    -   (d) DMF;    -   (e) ethanol;    -   (f) benzyl alcohol;    -   (g) dextrose-containing water for injection;    -   (h) Cremophor;    -   (i) cyclodextrin; and    -   (j) PEG.

In still another alternative, the composition comprises a substitutedhexitol derivative and a solvent system, wherein the solvent system isselected from the group consisting of:

-   -   (a) an emulsion;    -   (b) dimethylsulfoxide (DMSO);    -   (c) N-methylformamide (NMF)    -   (d) DMF;    -   (e) ethanol;    -   (f) benzyl alcohol;    -   (g) dextrose-containing water for injection;    -   (h) Cremophor;    -   (i) cyclodextrin; and    -   (j) PEG.

In yet another alternative, the composition comprises a substitutedhexitol derivative and an excipient, wherein the excipient is selectedfrom the group consisting of:

-   -   (a) mannitol;    -   (b) albumin;    -   (c) EDTA;    -   (d) sodium bisulfite;    -   (e) benzyl alcohol;    -   (f) a carbonate buffer; and    -   (g) a phosphate buffer.

In still another alternative, the substituted hexitol derivative isincorporated into a dosage form selected from the group consisting of:

-   -   (a) tablets;    -   (b) capsules;    -   (c) topical gels;    -   (d) topical creams;    -   (e) patches;    -   (f) suppositories; and    -   (g) lyophilized dosage fills.

In yet another alternative, the dianhydrogalactitol is incorporated intoa dosage kit and packaging selected from the group consisting of ambervials to protect from light and stoppers with specialized coatings toimprove shelf-life stability.

In still another alternative, the composition comprisesdianhydrogalactitol and a drug delivery system selected from the groupconsisting of:

-   -   (a) nanocrystals;    -   (b) bioerodible polymers;    -   (c) liposomes;    -   (d) slow release injectable gels; and    -   (e) microspheres.

In still another alternative, the substituted hexitol derivative ispresent in the composition in a drug conjugate form selected from thegroup consisting of:

-   -   (a) a polymer system;    -   (b) polylactides;    -   (c) polyglycolides;    -   (d) amino acids;    -   (e) peptides; and    -   (f) multivalent linkers.

In yet another alternative, the therapeutic agent is a modifiedsubstituted hexitol derivative and the modification is selected from thegroup consisting of:

-   -   (a) alteration of side chains to increase or decrease        lipophilicity;    -   (b) addition of an additional chemical functionality to alter a        property selected from the group consisting of reactivity,        electron affinity, and binding capacity; and    -   (c) alteration of salt form.

In still another alternative, the substituted hexitol derivative is inthe form of a prodrug system, wherein the prodrug system is selectedfrom the group consisting of:

-   -   (a) the use of enzyme sensitive esters;    -   (b) the use of dimers;    -   (c) the use of Schiff bases;    -   (d) the use of pyridoxal complexes; and    -   (e) the use of caffeine complexes.

In yet another alternative, the composition comprises a substitutedhexitol derivative and at least one additional therapeutic agent to forma multiple drug system, wherein the at least one additional therapeuticagent is selected from the group consisting of:

-   -   (a) an inhibitor of multi-drug resistance;    -   (b) a specific drug resistance inhibitor;    -   (c) a specific inhibitor of a selective enzyme;    -   (d) a signal transduction inhibitor;    -   (e) an inhibitor of a repair enzyme; and    -   (f) a topoisomerase inhibitor with non-overlapping side effects.

When a pharmaceutical composition according to the present inventionincludes a prodrug, prodrugs and active metabolites of a compound may beidentified using routine techniques known in the art. See, e.g.,Bertolini et al., J. Med. Chem., 40, 2011-2016 (1997); Shan et al., J.Pharm. Sci., 86 (7), 765-767; Bagshawe, Drug Dev. Res., 34, 220-230(1995); Bodor, Advances in Drug Res., 13, 224-331 (1984); Bundgaard,Design of Prodrugs (Elsevier Press 1985); Larsen, Design and Applicationof Prodrugs, Drug Design and Development (Krogsgaard-Larsen et al.,eds., Harwood Academic Publishers, 1991); Dear et al., J. Chromatogr. B,748, 281-293 (2000); Spraul et al., J. Pharmaceutical & BiomedicalAnalysis, 10, 601-605 (1992); and Prox et al., Xenobiol., 3, 103-112(1992).

When the pharmacologically active compound in a pharmaceuticalcomposition according to the present invention possesses a sufficientlyacidic, a sufficiently basic, or both a sufficiently acidic and asufficiently basic functional group, these group or groups canaccordingly react with any of a number of inorganic or organic bases,and inorganic and organic acids, to form a pharmaceutically acceptablesalt. Exemplary pharmaceutically acceptable salts include those saltsprepared by reaction of the pharmacologically active compound with amineral or organic acid or an inorganic base, such as salts includingsulfates, pyrosulfates, bisulfates, sulfites, bisulfites, phosphates,monohydrogenphosphates, dihydrogenphosphates, metaphosphates,pyrophosphates, chlorides, bromides, iodides, acetates, propionates,decanoates, caprylates, acrylates, formates, isobutyrates, caproates,heptanoates, propiolates, oxalates, malonates, succinates, suberates,sebacates, fumarates, maleates, butyne-1,4-dioates, hexyne-1,6-dioates,benzoates, chlorobenzoates, methyl benzoates, dinitrobenzoates,hydroxybenzoates, methoxybenzoates, phthalates, sulfonates,xylenesulfonates, phenylacetates, phenylpropionates, phenylbutyrates,citrates, lactates, β-hydroxybutyrates, glycolates, tartrates,methane-sulfonates, propanesulfonates, naphthalene-1-sulfonates,naphthalene-2-sulfonates, and mandelates. If the pharmacologicallyactive compound has one or more basic functional groups, the desiredpharmaceutically acceptable salt may be prepared by any suitable methodavailable in the art, for example, treatment of the free base with aninorganic acid, such as hydrochloric acid, hydrobromic acid, sulfuricacid, nitric acid, phosphoric acid and the like, or with an organicacid, such as acetic acid, maleic acid, succinic acid, mandelic acid,fumaric acid, malonic acid, pyruvic acid, oxalic acid, glycolic acid,salicylic acid, a pyranosidyl acid, such as glucuronic acid orgalacturonic acid, an alpha-hydroxy acid, such as citric acid ortartaric acid, an amino acid, such as aspartic acid or glutamic acid, anaromatic acid, such as benzoic acid or cinnamic acid, a sulfonic acid,such as p-toluenesulfonic acid or ethanesulfonic acid, or the like. Ifthe pharmacologically active compound has one or more acidic functionalgroups, the desired pharmaceutically acceptable salt may be prepared byany suitable method available in the art, for example, treatment of thefree acid with an inorganic or organic base, such as an amine (primary,secondary or tertiary), an alkali metal hydroxide or alkaline earthmetal hydroxide, or the like. Illustrative examples of suitable saltsinclude organic salts derived from amino acids, such as glycine andarginine, ammonia, primary, secondary, and tertiary amines, and cyclicamines, such as piperidine, morpholine and piperazine, and inorganicsalts derived from sodium, calcium, potassium, magnesium, manganese,iron, copper, zinc, aluminum and lithium.

In the case of agents that are solids, it is understood by those skilledin the art that the inventive compounds and salts may exist in differentcrystal or polymorphic forms, all of which are intended to be within thescope of the present invention and specified formulas.

The amount of a given pharmacologically active agent, such as asubstituted hexitol derivative such as dianhydrogalactitol or an analogor derivative of dianhydrogalactitol as described above, that isincluded in a unit dose of a pharmaceutical composition according to thepresent invention will vary depending upon factors such as theparticular compound, disease condition and its severity, the identity(e.g., weight) of the subject in need of treatment, but can neverthelessbe routinely determined by one skilled in the art. Typically, suchpharmaceutical compositions include a therapeutically effective quantityof the pharmacologically active agent and an inert pharmaceuticallyacceptable carrier or diluent. Typically, these compositions areprepared in unit dosage form appropriate for the chosen route ofadministration, such as oral administration or parenteraladministration. A pharmacologically active agent as described above canbe administered in conventional dosage form prepared by combining atherapeutically effective amount of such a pharmacologically activeagent as an active ingredient with appropriate pharmaceutical carriersor diluents according to conventional procedures. These procedures mayinvolve mixing, granulating and compressing or dissolving theingredients as appropriate to the desired preparation. Thepharmaceutical carrier employed may be either a solid or liquid.Exemplary of solid carriers are lactose, sucrose, talc, gelatin, agar,pectin, acacia, magnesium stearate, stearic acid and the like. Exemplaryof liquid carriers are syrup, peanut oil, olive oil, water and the like.Similarly, the carrier or diluent may include time-delay or time-releasematerial known in the art, such as glyceryl monostearate or glyceryldistearate alone or with a wax, ethylcellulose,hydroxypropylmethylcellulose, methylmethacrylate and the like.

A variety of pharmaceutical forms can be employed. Thus, if a solidcarrier is used, the preparation can be tableted, placed in a hardgelatin capsule in powder or pellet form or in the form of a troche orlozenge. The amount of solid carrier may vary, but generally will befrom about 25 mg to about 1 g. If a liquid carrier is used, thepreparation will be in the form of syrup, emulsion, soft gelatincapsule, sterile injectable solution or suspension in an ampoule or vialor non-aqueous liquid suspension.

To obtain a stable water-soluble dose form, a pharmaceuticallyacceptable salt of a pharmacologically active agent as described aboveis dissolved in an aqueous solution of an organic or inorganic acid,such as 0.3 M solution of succinic acid or citric acid. If a solublesalt form is not available, the agent may be dissolved in a suitablecosolvent or combinations of cosolvents. Examples of suitable cosolventsinclude, but are not limited to, alcohol, propylene glycol, polyethyleneglycol 300, polysorbate 80, glycerin and the like in concentrationsranging from 0-60% of the total volume. In an exemplary embodiment, acompound of Formula I is dissolved in DMSO and diluted with water. Thecomposition may also be in the form of a solution of a salt form of theactive ingredient in an appropriate aqueous vehicle such as water orisotonic saline or dextrose solution.

It will be appreciated that the actual dosages of the agents used in thecompositions of this invention will vary according to the particularcomplex being used, the particular composition formulated, the mode ofadministration and the particular site, host and disease and/orcondition being treated. Actual dosage levels of the active ingredientsin the pharmaceutical compositions of the present invention can bevaried so as to obtain an amount of the active ingredient which iseffective to achieve the desired therapeutic response for a particularsubject, composition, and mode of administration, without being toxic tothe subject. The selected dosage level depends upon a variety ofpharmacokinetic factors including the activity of the particulartherapeutic agent, the route of administration, the time ofadministration, the rate of excretion of the particular compound beingemployed, the severity of the condition, other health considerationsaffecting the subject, and the status of liver and kidney function ofthe subject. It also depends on the duration of the treatment, otherdrugs, compounds and/or materials used in combination with theparticular therapeutic agent employed, as well as the age, weight,condition, general health and prior medical history of the subject beingtreated, and like factors. Methods for determining optimal dosages aredescribed in the art, e.g., Remington: The Science and Practice ofPharmacy, Mack Publishing Co., 20^(th) ed., 2000. Optimal dosages for agiven set of conditions can be ascertained by those skilled in the artusing conventional dosage-determination tests in view of theexperimental data for an agent. For oral administration, an exemplarydaily dose generally employed is from about 0.001 to about 3000 mg/kg ofbody weight, with courses of treatment repeated at appropriateintervals. In some embodiments, the daily dose is from about 1 to 3000mg/kg of body weight.

Typical daily doses in a patient may be anywhere between about 500 mg toabout 3000 mg, given once or twice daily, e.g., 3000 mg can be giventwice daily for a total dose of 6000 mg. In one embodiment, the dose isbetween about 1000 to about 3000 mg. In another embodiment, the dose isbetween about 1500 to about 2800 mg. In other embodiments, the dose isbetween about 2000 to about 3000 mg. Typically, doses are from about 1mg/m² to about 40 mg/m². Preferably, doses are from about 5 mg/m² toabout 25 mg/m². Additional alternatives for dosages are as describedabove with respect to schedules of administration and dose modification.Dosages can be varied according to the therapeutic response.

Plasma concentrations in the subjects may be between about 100 μM toabout 1000 μM. In some embodiments, the plasma concentration may bebetween about 200 μM to about 800 μM. In other embodiments, theconcentration is about 300 μM to about 600 μM. In still otherembodiments the plasma concentration may be between about 400 to about800 μM. In another alternative, the plasma concentration can be betweenabout 0.5 μM to about 20 μM, typically 1 μM to about 10 μM.Administration of prodrugs is typically dosed at weight levels, whichare chemically equivalent to the weight levels of the fully active form.

The compositions of the invention may be manufactured using techniquesgenerally known for preparing pharmaceutical compositions, e.g., byconventional techniques such as mixing, dissolving, granulating,dragee-making, levitating, emulsifying, encapsulating, entrapping orlyophilizing. Pharmaceutical compositions may be formulated in aconventional manner using one or more physiologically acceptablecarriers, which may be selected from excipients and auxiliaries thatfacilitate processing of the active compounds into preparations, whichcan be used pharmaceutically.

Proper formulation is dependent upon the route of administration chosen.For injection, the agents of the invention may be formulated intoaqueous solutions, preferably in physiologically compatible buffers suchas Hanks's solution, Ringer's solution, or physiological saline buffer.For transmucosal administration, penetrants appropriate to the barrierto be permeated are used in the formulation. Such penetrants aregenerally known in the art.

For oral administration, the compounds can be formulated readily bycombining the active compounds with pharmaceutically acceptable carriersknown in the art. Such carriers enable the compounds of the invention tobe formulated as tablets, pills, dragees, capsules, liquids, gels,syrups, slurries, solutions, suspensions and the like, for oralingestion by a patient to be treated. Pharmaceutical preparations fororal use can be obtained using a solid excipient in admixture with theactive ingredient (agent), optionally grinding the resulting mixture,and processing the mixture of granules after adding suitableauxiliaries, if desired, to obtain tablets or dragee cores. Suitableexcipients include: fillers such as sugars, including lactose, sucrose,mannitol, or sorbitol; and cellulose preparations, for example, maizestarch, wheat starch, rice starch, potato starch, gelatin, gum, methylcellulose, hydroxypropylmethyl-cellulose, sodium carboxymethylcellulose,or polyvinylpyrrolidone (PVP). If desired, disintegrating agents may beadded, such as crosslinked polyvinyl pyrrolidone, agar, or alginic acidor a salt thereof such as sodium alginate.

Dragee cores are provided with suitable coatings. For this purpose,concentrated sugar solutions may be used, which may optionally containgum arabic, polyvinyl pyrrolidone, Carbopol gel, polyethylene glycol,and/or titanium dioxide, lacquer solutions, and suitable organicsolvents or solvent mixtures. Dyestuffs or pigments may be added to thetablets or dragee coatings for identification or to characterizedifferent combinations of active agents.

Pharmaceutical preparations which can be used orally include push-fitcapsules made of gelatin, as well as soft, sealed capsules made ofgelatin and a plasticizer, such as glycerol or sorbitol. The push-fitcapsules can contain the active ingredients in admixture with fillerssuch as lactose, binders such as starches, and/or lubricants such astalc or magnesium stearate, and, optionally, stabilizers. In softcapsules, the active agents may be dissolved or suspended in suitableliquids, such as fatty oils, liquid paraffin, or liquid polyethyleneglycols. In addition, stabilizers may be added. All formulations fororal administration should be in dosages suitable for suchadministration. For buccal administration, the compositions may take theform of tablets or lozenges formulated in conventional manner.

Pharmaceutical formulations for parenteral administration can includeaqueous solutions or suspensions. Suitable lipophilic solvents orvehicles include fatty oils such as sesame oil or synthetic fatty acidesters, such as ethyl oleate or triglycerides. Aqueous injectionsuspensions may contain substances which increase the viscosity of thesuspension, such as sodium carboxymethyl cellulose, sorbitol, ordextran. Optionally, the suspension may also contain suitablestabilizers or modulators which increase the solubility ordispersibility of the composition to allow for the preparation of highlyconcentrated solutions, or can contain suspending or dispersing agents.Pharmaceutical preparations for oral use can be obtained by combiningthe pharmacologically active agent with solid excipients, optionallygrinding a resulting mixture, and processing the mixture of granules,after adding suitable auxiliaries, if desired, to obtain tablets ordragee cores. Suitable excipients are, in particular, fillers such assugars, including lactose, sucrose, mannitol, or sorbitol; cellulosepreparations such as, for example, maize starch, wheat starch, ricestarch, potato starch, gelatin, gum tragacanth, methyl cellulose,hydroxypropylmethyl-cellulose, sodium carboxymethylcellulose, and/orpolyvinylpyrrolidone (PVP). If desired, disintegrating modulators may beadded, such as the cross-linked polyvinyl pyrrolidone, agar, or alginicacid or a salt thereof such as sodium alginate.

Other ingredients such as stabilizers, for example, antioxidants such assodium citrate, ascorbyl palmitate, propyl gallate, reducing agents,ascorbic acid, vitamin E, sodium bisulfite, butylated hydroxytoluene,BHA, acetylcysteine, monothioglycerol, phenyl-α-naphthylamine, orlecithin can be used. Also, chelators such as EDTA can be used. Otheringredients that are conventional in the area of pharmaceuticalcompositions and formulations, such as lubricants in tablets or pills,coloring agents, or flavoring agents, can be used. Also, conventionalpharmaceutical excipients or carriers can be used. The pharmaceuticalexcipients can include, but are not necessarily limited to, calciumcarbonate, calcium phosphate, various sugars or types of starch,cellulose derivatives, gelatin, vegetable oils, polyethylene glycols andphysiologically compatible solvents. Other pharmaceutical excipients arewell known in the art. Exemplary pharmaceutically acceptable carriersinclude, but are not limited to, any and/or all of solvents, includingaqueous and non-aqueous solvents, dispersion media, coatings,antibacterial and/or antifungal agents, isotonic and/or absorptiondelaying agents, and/or the like. The use of such media and/or agentsfor pharmaceutically active substances is well known in the art. Exceptinsofar as any conventional medium, carrier, or agent is incompatiblewith the active ingredient or ingredients, its use in a compositionaccording to the present invention is contemplated. Supplementary activeingredients can also be incorporated into the compositions, particularlyas described above. For administration of any of the compounds used inthe present invention, preparations should meet sterility, pyrogenicity,general safety, and purity standards as required by the FDA Office ofBiologics Standards or by other regulatory organizations regulatingdrugs.

For administration intranasally or by inhalation, the compounds for useaccording to the present invention are conveniently delivered in theform of an aerosol spray presentation from pressurized packs or anebulizer, with the use of a suitable propellant, e.g.,dichlorodifluoromethane, trichlorofluoromethane,dichlorotetrafluoroethane, carbon dioxide or other suitable gas. In thecase of a pressurized aerosol, the dosage unit may be determined byproviding a valve to deliver a metered amount. Capsules and cartridgesof gelatin for use in an inhaler or insufflator and the like may beformulated containing a powder mix of the compound and a suitable powderbase such as lactose or starch.

The compounds may be formulated for parenteral administration byinjection, e.g., by bolus injection or continuous infusion. Formulationsfor injection may be presented in unit-dosage form, e.g., in ampules orin multi-dose containers, with an added preservative. The compositionsmay take such forms as suspensions, solutions or emulsions in oily oraqueous vehicles, and may contain formulatory agents such as suspending,stabilizing and/or dispersing agents.

Pharmaceutical formulations for parenteral administration includeaqueous solutions of the active compounds in water-soluble form.Additionally, suspensions of the active agents may be prepared asappropriate oily injection suspensions. Suitable lipophilic solvents orvehicles include fatty oils such as sesame oil, or synthetic fatty acidesters, such as ethyl oleate or triglycerides, or liposomes. Aqueousinjection suspensions may contain substances that increase the viscosityof the suspension, such as sodium carboxymethyl cellulose, sorbitol, ordextran. Optionally, the suspension may also contain suitablestabilizers or agents, which increase the solubility of the compounds toallow for the preparation of highly concentrated solutions.

Alternatively, the active ingredient may be in powder form forconstitution with a suitable vehicle, e.g., sterile pyrogen-free water,before use. The compounds may also be formulated in rectal compositionssuch as suppositories or retention enemas, e.g., containing conventionalsuppository bases such as cocoa butter or other glycerides.

In addition to the formulations described above, the compounds may alsobe formulated as a depot preparation. Such long-acting formulations maybe administered by implantation (for example, subcutaneously orintramuscularly) or by intramuscular injection. Thus, for example, thecompounds may be formulated with suitable polymeric or hydrophobicmaterials (for example, as an emulsion in an acceptable oil) orion-exchange resins, or as sparingly soluble derivatives, for example,as a sparingly soluble salt.

An exemplary pharmaceutical carrier for hydrophobic compounds is acosolvent system comprising benzyl alcohol, a nonpolar surfactant, awater-miscible organic polymer, and an aqueous phase. The cosolventsystem may be a VPD co-solvent system. VPD is a solution of 3% w/vbenzyl alcohol, 8% w/v of the nonpolar surfactant polysorbate 80, and65% w/v polyethylene glycol 300, made up to volume in absolute ethanol.The VPD co-solvent system (VPD:5W) contains VPD diluted 1:1 with a 5%dextrose in water solution. This co-solvent system dissolves hydrophobiccompounds well, and itself produces low toxicity upon systemicadministration. Naturally, the proportions of a co-solvent system may bevaried considerably without destroying its solubility and toxicitycharacteristics. Furthermore, the identity of the co-solvent componentsmay be varied: for example, other low-toxicity nonpolar surfactants maybe used instead of polysorbate 80; the fraction size of polyethyleneglycol may be varied; other biocompatible polymers may replacepolyethylene glycol, e.g. polyvinyl pyrrolidone; and other sugars orpolysaccharides may be substituted for dextrose.

Alternatively, other delivery systems for hydrophobic pharmaceuticalcompounds may be employed. Liposomes and emulsions are known examples ofdelivery vehicles or carriers for hydrophobic drugs. Certain organicsolvents such as dimethylsulfoxide also may be employed, althoughusually at the cost of greater toxicity. Additionally, the compounds maybe delivered using a sustained-release system, such as semipermeablematrices of solid hydrophobic polymers containing the therapeutic agent.Various sustained-release materials have been established and are knownby those skilled in the art. Sustained-release capsules may, dependingon their chemical nature, release the compounds for a few weeks up toover 100 days; in other alternatives, depending on the therapeutic agentand the formulation employed, release may occur over hours, days, weeks,or months. Depending on the chemical nature and the biological stabilityof the therapeutic reagent, additional strategies for proteinstabilization may be employed.

The pharmaceutical compositions also may comprise suitable solid- orgel-phase carriers or excipients. Examples of such carriers orexcipients include calcium carbonate, calcium phosphate, sugars,starches, cellulose derivatives, gelatin, and polymers such aspolyethylene glycols.

A pharmaceutical composition can be administered by a variety of methodsknown in the art. The routes and/or modes of administration varydepending upon the desired results. Depending on the route ofadministration, the pharmacologically active agent may be coated in amaterial to protect the targeting composition or other therapeutic agentfrom the action of acids and other compounds that may inactivate theagent. Conventional pharmaceutical practice can be employed to providesuitable formulations or compositions for the administration of suchpharmaceutical compositions to subjects. Any appropriate route ofadministration can be employed, for example, but not limited to,intravenous, parenteral, intraperitoneal, intravenous, transcutaneous,subcutaneous, intramuscular, intraurethral, or oral administration.Depending on the severity of the malignancy or other disease, disorder,or condition to be treated, as well as other conditions affecting thesubject to be treated, either systemic or localized delivery of thepharmaceutical composition can be used in the course of treatment. Thepharmaceutical composition as described above can be administeredtogether with additional therapeutic agents intended to treat aparticular disease or condition, which may be the same disease orcondition that the pharmaceutical composition is intended to treat,which may be a related disease or condition, or which even may be anunrelated disease or condition.

Pharmaceutical compositions according to the present invention can beprepared in accordance with methods well known and routinely practicedin the art. See, e.g., Remington: The Science and Practice of Pharmacy,Mack Publishing Co., 20^(th) ed., 2000; and Sustained and ControlledRelease Drug Delivery Systems, J. R. Robinson, ed., Marcel Dekker, Inc.,New York, 1978. Pharmaceutical compositions are preferably manufacturedunder GMP conditions. Formulations for parenteral administration may,for example, contain excipients, sterile water, or saline, polyalkyleneglycols such as polyethylene glycol, oils of vegetable origin, orhydrogenated naphthalenes. Biocompatible, biodegradable lactidepolymers, lactide/glycolide copolymers, orpolyoxyethylene-polyoxypropylene copolymers may be used to control therelease of the compounds. Other potentially useful parenteral deliverysystems for molecules of the invention include ethylene-vinyl acetatecopolymer particles, osmotic pumps, and implantable infusion systems.Formulations for inhalation may contain excipients, for example,lactose, or may be aqueous solutions containing, e.g.,polyoxyethylene-9-lauryl ether, glycocholate and deoxycholate, or can beoily solutions for administration or gels.

Pharmaceutical compositions according to the present invention areusually administered to the subjects on multiple occasions. Intervalsbetween single dosages can be weekly, monthly or yearly. Intervals canalso be irregular as indicated by therapeutic response or otherparameters well known in the art. Alternatively, the pharmaceuticalcomposition can be administered as a sustained release formulation, inwhich case less frequent administration is required. Dosage andfrequency vary depending on the half-life in the subject of thepharmacologically active agent included in a pharmaceutical composition.The dosage and frequency of administration can vary depending on whetherthe treatment is prophylactic or therapeutic. In prophylacticapplications, a relatively low dosage is administered at relativelyinfrequent intervals over a long period of time. Some subjects maycontinue to receive treatment for the rest of their lives. Intherapeutic applications, a relatively high dosage at relatively shortintervals is sometimes required until progression of the disease isreduced or terminated, and preferably until the subject shows partial orcomplete amelioration of symptoms of disease. Thereafter, the subjectcan be administered a prophylactic regime.

For the purposes of the present application, treatment can be monitoredby observing one or more of the improving symptoms associated with thedisease, disorder, or condition being treated, or by observing one ormore of the improving clinical parameters associated with the disease,disorder, or condition being treated. In the case of glioblastomamultiforme, the clinical parameters can include, but are not limited to,reduction in tumor burden, reduction in pain, reduction in edema of thebrain, reduction in frequency or severity of seizures, reduction infrequency or severity of vomiting, reduction of frequency or severity ofheadache, reduction in memory deficit, reduction in neurologicaldeficit, and reduction in occurrence of tumor spread or metastasis. Asused herein, the terms “treatment,” “treating,” or equivalentterminology are not intended to imply a permanent cure for the disease,disorder, or condition being treated. Compositions and methods accordingto the present invention are not limited to treatment of humans, but areapplicable to treatment of socially or economically important animals,such as dogs, cats, horses, cows, sheep, goats, pigs, and other animalspecies of social or economic importance. Unless specifically stated,compositions and methods according to the present invention are notlimited to the treatment of humans.

Sustained-release formulations or controlled-release formulations arewell-known in the art. For example, the sustained-release orcontrolled-release formulation can be (1) an oral matrixsustained-release or controlled-release formulation; (2) an oralmultilayered sustained-release or controlled-release tablet formulation;(3) an oral multiparticulate sustained-release or controlled-releaseformulation; (4) an oral osmotic sustained-release or controlled-releaseformulation; (5) an oral chewable sustained-release orcontrolled-release formulation; or (6) a dermal sustained-release orcontrolled-release patch formulation.

The pharmacokinetic principles of controlled drug delivery aredescribed, for example, in B. M. Silber et al.,“Pharmacokinetic/Pharmacodynamic Basis of Controlled Drug Delivery” inControlled Drug Delivery: Fundamentals and Applications (J. R. Robinson& V. H. L. Lee, eds, 2d ed., Marcel Dekker, New York, 1987), ch. 5, pp.213-251, incorporated herein by this reference.

One of ordinary skill in the art can readily prepare formulations forcontrolled release or sustained release comprising a pharmacologicallyactive agent according to the present invention by modifying theformulations described above, such as according to principles disclosedin V. H. K. Li et al, “Influence of Drug Properties and Routes of DrugAdministration on the Design of Sustained and Controlled ReleaseSystems” in Controlled Drug Delivery: Fundamentals and Applications (J.R. Robinson & V. H. L. Lee, eds, 2d ed., Marcel Dekker, New York, 1987),ch. 1, pp. 3-94, incorporated herein by this reference. This process ofpreparation typically takes into account physicochemical properties ofthe pharmacologically active agent, such as aqueous solubility,partition coefficient, molecular size, stability, and nonspecificbinding to proteins and other biological macromolecules. This process ofpreparation also takes into account biological factors, such asabsorption, distribution, metabolism, duration of action, the possibleexistence of side effects, and margin of safety, for thepharmacologically active agent. Accordingly, one of ordinary skill inthe art could modify the formulations into a formulation having thedesirable properties described above for a particular application.

U.S. Pat. No. 6,573,292 by Nardella, U.S. Pat. No. 6,921,722 byNardella, U.S. Pat. No. 7,314,886 to Chao et al., and U.S. Pat. No.7,446,122 by Chao et al., which disclose methods of use of variouspharmacologically active agents and pharmaceutical compositions intreating a number of diseases and conditions, including cancer, andmethods of determining the therapeutic effectiveness of suchpharmacologically active agents and pharmaceutical compositions, are allincorporated herein by this reference.

In view of the results reported in the Example below, another aspect ofthe present invention is a method of treating glioblastoma multiformecomprising the step of administering a therapeutically effectivequantity of a substituted hexitol derivative such as dianhydrogalactitolto a patient suffering from the malignancy.

Typically, when the substituted hexitol derivative isdianhydrogalactitol, the therapeutically effective quantity ofdianhydrogalactitol is from about 1 mg/m² to about 40 mg/m². Preferably,the therapeutically effective quantity of dianhydrogalactitol is fromabout 5 mg/m² to about 25 mg/m². Therapeutically active quantities ofsubstituted hexitol derivatives other than dianhydrogalactitol can bedetermined by one of ordinary skill in the art by using the molecularweight of the particular substituted hexitol derivative and the activityof the particular substituted hexitol derivative, such as the in vitroactivity of the substituted hexitol derivative against a standard cellline. Other suitable dosages are described in the Examples.

Typically, the substituted hexitol derivative such asdianhydrogalactitol is administered by a route selected from the groupconsisting of intravenous and oral. Preferably, the substituted hexitolderivative such as dianhydrogalactitol is administered intravenously.

The method can further comprise the step of administering atherapeutically effective dose of ionizing radiation. The method canfurther comprise the step of administering a therapeutically effectivequantity of temozolomide, bevacizumab, or a corticosteroid. In anotheralternative, the method can further comprise the step of administering atherapeutically effective quantity of at least one chemotherapeuticagent selected from the group consisting of lomustine, cisplatin,carboplatin, vincristine, and cyclophosphamide. Suitable methods foradministration of these agents and suitable dosages are well known inthe art.

Typically, the substituted hexitol derivative such asdianhydrogalactitol substantially suppresses the growth of cancer stemcells (CSCs). Typically, the suppression of the growth of cancer stemcells is at least 50%. Preferably, the suppression of the growth ofcancer stem cells is at least 99%.

Typically, the substituted hexitol derivative such asdianhydrogalactitol is effective in suppressing the growth of cancercells possessing O⁶-methylguanine-DNA methyltransferase (MGMT)-drivendrug resistance. Typically, the substituted hexitol derivative such asdianhydrogalactitol is also effective in suppressing the growth ofcancer cells resistant to temozolomide.

The method can further comprise the administration of a therapeuticallyeffective quantity of a tyrosine kinase inhibitor as described above.

The method can further comprise the administration of a therapeuticallyeffective quantity of an epidermal growth factor receptor (EGFR)inhibitor as described above. The EGFR inhibitor can affect eitherwild-type binding sites or mutated binding sites, including EGFR VariantIII, as described above.

The invention is illustrated by the following Examples. These Examplesare included for illustrative purposes only, and are not intended tolimit the invention.

Example 1 Use of Dianhydrogalactitol to Inhibit Growth of GlioblastomaMultiforme and Medulloblastoma Cells

Materials and Methods:

Cell Lines and Culture Conditions:

All cells were cultured in DMEM (Dulbecco's Modified Eagle's medium;Invitrogen/Gibco) with 10% FBS (fetal bovine serum; Invitrogen/Gibco) at37° C. with 5% CO₂, and subcultured twice weekly during the experimentalperiod.

Drugs:

Temozolomide (TMZ) was purchased from Sigma Aldrich and dissolved indimethyl sulfoxide (DMSO) (Sigma-Aldrich). A stock solution of 100 mMwas kept at −20° C. before use. Dianhydrogalactitol (DAG; results withDAG are shown as “VAL” in the figures) was provided by Del MarPharmaceuticals Ltd. A stock solution of 100 mM was prepared bydissolving the lyophilized powder in the injection vial in sterilephosphate buffered saline (PBS) and kept at 20° C. before use.

Growth Assays:

Each cell line used was seeded at 3000 cells/well in 100 μL medium in a96-well plate (BD Falcon) and incubated overnight. Cells were thentreated with TMZ or DAG at concentrations of 0.1-100 μM in fresh mediumfor 72 hours. The cells were fixed in 2% paraformaldehyde(Sigma-Aldrich) with nuclear dye Hoechst 33342 (1 μg/mL)(Sigma-Aldrich). After gentle washing with PBS, the cells were kept infresh PBS and the plates were kept at 4° C. in the dark before HCS (highcontent screening (ThermoFisher Scientific) analysis. Twenty view fieldsper well were scanned and analyzed. Growth inhibition was calculated asa percentage of the control without the solvent and the drug; thesamples treated with solvent alone served as a reference. There werethree replicates for each treatment and the experiments were repeatedonce.

Results

FIG. 1 is a chart showing three GBM cell lines used and showing theirdegree of temozolomide (TMZ) resistance and the status of methylation ofthe promoter of the O⁶-methylguanine-DNA methyltransferase (MGMT) gene.In general, an increase of methylation of the MGMT promoter isassociated with improved outcome in GBM.

FIG. 2A is a graph showing the inhibition of growth of the GBM cell lineSF188 with increasing concentrations of TMZ and dianhydrogalactitol(DAG; shown as “VAL” in the figures) (two experiments each). In FIG. 2A,(♦) represents TMZ results and (▪) represents DAG results. FIG. 2Aclearly shows that dianhydrogalactitol is a more efficient inhibitor ofgrowth of the GBM cell line SF188 than TMZ.

FIG. 2B is a graph showing the inhibition of growth of the GBM cell lineU251 with increasing concentrations of TMZ and DAG (two experimentseach). In FIG. 2B, (♦) represents TMZ results and (▪) represents DAGresults. FIG. 2B clearly shows that dianhydrogalactitol is a moreefficient inhibitor of growth of the GBM cell line U251 than TMZ.

FIG. 2C is a graph showing the inhibition of growth of the GBM cell lineT98G with increasing concentrations of TMZ and DAG (two experimentseach). In FIG. 2C, (♦) represents TMZ results and (▪) represents DAGresults. FIG. 2C clearly shows that dianhydrogalactitol is a moreefficient inhibitor of growth of the GBM cell line T98G than TMZ.

FIG. 3 is a chart showing the three cell lines used in FIGS. 2A, 2B, and2C, indicating TMZ resistance and MGMT status.

FIG. 4 is a photograph showing that DAG at 5 μM inhibits colonyformation by the GBM cell line SF188 by more than 95% after 7 days.

FIG. 5 is a graph showing that DAG inhibits the growth of SF188 cellsmore effectively than TMZ, particularly in secondary sphere formation.BT74 cells are notably TMZ resistant; therefore, the activity of DAG inthis setting illustrates activity in otherwise insensitive cells.

FIG. 6 shows that DAG completely inhibits secondary neurosphereformation by BT74 cancer stem cells and substantially inhibits primaryneurosphere formation; photomicrographs are shown at the top, and graphsshowing the extent of inhibition are shown under the photomicrographs.

FIG. 7 is a graph showing that DAG is more efficient at inhibitingprimary neurosphere formation than TMZ for SF188 and DAOY cell lines.DAOY is a medulloblastoma cell line.

FIG. 8 is a photograph showing that DAG at 5 μM completely inhibitscolony formation by the medulloblastoma cell line DAOY after 7 days.

FIG. 9 is a graph and comparative photomicrographs showing that BT74cells do not show significant sensitivity to TMZ.

FIG. 10 is a graph showing the effect of DAG on primary adult GBM cellsisolated fresh from BCCH, showing a substantial degree of inhibition;TMZ essentially has no effect on these cells.

FIG. 11 is a set of graphs showing effect of combination treatments withTMZ and DAG on SF188 cells, showing inhibition of neurosphere formation;the combination of TMZ plus DAG provided the greatest degree ofinhibition.

FIG. 12 is a set of graphs showing effect of combination treatments withTMZ and DAG on SF188 cells, showing inhibition of colony formation; thecombination of TMZ plus DAG provided the greatest degree of inhibition.

Conclusions:

Glioblastoma (GBM) remains one of the most difficult tumors to treat inpart because many new agents fail to cross the blood brain barrier (BBB)and secondly due to intrinsic drug resistance. Temozolomide (TMZ) is afront-line therapy for the treatment of GBM, however, it is oftenineffective due to drug inactivation by O⁶-methylguanine-DNAmethyltransferase (MGMT). Cancer stem cells (CSC) are a subpopulation ofthe tumor that resist therapy and give rise to relapse. Here wedescribed dianhydrogalactitol (DAG), a novel alkylating agent thatcreates N⁷ methylation on DNA, which was initially intriguing because itcrosses the BBB. We addressed how it compared to TMZ, whether it couldbe used to overcome MGMT-driven drug resistance and if has activityagainst CSCs. Addressing these questions provides further preclinicalsupport for DAG, which is currently undergoing human clinical trials inthe USA against refractory GBM.

DAG inhibited U251 and SF188 cell growth in monolayer and asneurospheres more effectively than TMZ and caused apoptosis after 72hrs. In a 10-day colony formation assay, DAG (5 μM) suppressed SF188growth by ˜95%. T98G cells are classically TMZ resistant and expressMGMT yet DAG inhibited their growth in monolayer after 72 hrs in adose-dependent manner (IC50=5 μM). DAG also significantly inhibited thegrowth of primary glioblastoma multiforme cells that were completelyresistant to TMZ. DAG also inhibited the growth of CSCs by 100% inneurosphere growth assays. In summary, DAG has better in vitro efficacythan TMZ against brain tumor cells, can overcome resistance associatedwith MGMT, and targets brain tumor CSCs, demonstrating that it has thepotential to surpass the current standard of care. DAG is also extremelyeffective in combination with TMZ, showing efficient inhibition ofneurosphere formation and secondary colony formation in combination withthat drug.

In conclusion, dianhydrogalactitol shows substantially more activity ininhibiting the growth of glioblastoma multiforme cell lines than doesthe conventionally accepted gold standard for glioblastoma multiformechemotherapy, temozolomide. Dianhydrogalactitol also suppresses colonyformation and proliferation by cancer stem cells. Dianhydrogalactitolalso is an effective growth inhibitor of a medulloblastoma cell line.

The data of this Example demonstrates that dianhydrogalactitol is activeagainst tumors that are refractory to temozolomide. The data of thisExample also demonstrates that dianhydrogalactitol acts independently ofthe O⁶-methylguanine-DNA methyltransferase (MGMT) repair mechanism. Theactivity of dianhydrogalactitol was also demonstrated in medulloblastomaand in childhood, as well as adult, glioblastoma multiforme.Importantly, dianhydrogalactitol has demonstrated activity againstcancer stem cells, as demonstrated by the neurosphere data. Additionallydianhydrogalactitol can be combined with TMZ for improved therapeuticefficiency.

The results of this Example show that dianhydrogalactitol hassubstantial activity against both glioblastoma multiforme andmedulloblastoma cell lines under conditions in which the activity wouldappear to correlate well with in vivo effectiveness of achemotherapeutic agent in treating these malignancies.

Example 2 Study of Dianhydrogalactitol in Patients with RecurrentGlioblastoma Multiforme

Median survival for patients with recurrent glioblastoma multiforme(GBM) is less than 6 months. Front-line systemic therapy is temozolomide(TMZ), but chemo-resistance due toO⁶-methylguanine-DNA-methyltransferase (MGMT) activity has beenimplicated in poor outcomes. Dianhydrogalactitol is a structurallyunique bifunctional DNA alkylating small molecule drug that crosses theblood-brain barrier and accumulates in brain tumor tissue. Inpreclinical in vitro studies, dianhydrogalactitol demonstrated activityin a wide range of cancer cell lines, including pediatric and adult GBMcell lines and GBM stem cells. Notably, dianhydrogalactitol overcomeschemo-resistance induced by MGMT in vitro. A new clinical study has beeninitiated with the primary objective of establishing the maximumtolerated dose (MTD) and identifying a dose and dosing regimen forfurther study. Dose-limiting toxicity is expected to bemyelosuppression, the management of which has improved in recent years.Initially, a cumulative dose of 150 mg/m² repeated each month wasrecommended as a safe and effective starting dose (R. T. Eagan et al.,“Phase I Study of a Five-Day Intermittent Schedule for1,2:5,6-Dianhydrogalactitol (NSC-132313),” J. Natl. Cancer Inst. 56:179-181 (1976); C. D. Haas et al., “Phase I Evaluation ofDianhydrogalactitol (NSC-132313),” Cancer Treat. Rep. 60: 611-614(1976), both of which are incorporated herein by this reference) and acumulative dose of 125 mg/m² delivered in a 33-day cycle in combinationwith radiation was demonstrated to be superior to radiation alone (R. T.Eagan et al., “Dianhydrogalactitol and Radiation Therapy. Treatment ofSupratentorial Glioma,” J. Am. Med. Assoc. 241: 2046-2050 (1979),incorporated herein by this reference). In the study reported in thisExample, the cumulative dose in a 33-day cycle ranges from 9 mg/m²(cohort 1) to 240 mg/m² (cohort 7). Five dose cohorts, with the highestcumulative dose in a 33-day cycle of 120 mg/m², have completed the trialsuccessfully with no drug-related serious adverse events (SAEs) and amaximum tolerated dose (MTD) had not been reached. The methods of thestudy reported in this Example were as follows: The study was anopen-label, single-arm Phase I/II dose-escalation study in patients withhistologically-confirmed initial diagnosis of malignant GBM. The studyutilized a 3+3 dose-escalation design. Patients receiveddianhydrogalactitol on days 1, 2, and 3 of a 21-day cycle. The GBMpatients have previously been treated with surgery and/or radiation, ifappropriate, and must have failed both temozolomide and bevacizumab,unless contraindicated.

Pharmacokinetic analyses show dose-dependent increase in exposure with ashort 1-2 hour plasma half-life and a C_(max) of <200 ng/ml at 10 mg/m².Historical data suggests a long life in the CSF (>20 hours) withpreferential accumulation to brain tumor tissue.

ADVANTAGES OF THE INVENTION

The present invention provides improved methods and compositionsemploying dianhydrogalactitol for the treatment of glioblastomamultiforme, a type of malignant brain tumor that has proven resistant tochemotherapy by conventional means.

The use of dianhydrogalactitol to treat glioblastoma multiforme isexpected to be well tolerated and not to result in additional sideeffects, an important consideration when many of the treatmentmodalities currently in use for this brain malignancy result incognitive and physical impairments. Dianhydrogalactitol can be usedtogether with radiation or other chemotherapeutic agents.

Methods according to the present invention possess industrialapplicability for the preparation of a medicament for the treatment ofglioblastoma multiforme. Compositions according to the present inventionpossess industrial applicability as pharmaceutical compositions.

The method claims of the present invention provide specific method stepsthat are more than general applications of laws of nature and requirethat those practicing the method steps employ steps other than thoseconventionally known in the art, in addition to the specificapplications of laws of nature recited or implied in the claims, andthus confine the scope of the claims to the specific applicationsrecited therein. In some contexts, these claims are directed to new waysof using an existing drug.

The inventions illustratively described herein can suitably be practicedin the absence of any element or elements, limitation or limitations,not specifically disclosed herein. Thus, for example, the terms“comprising,” “including,” “containing,” etc. shall be read expansivelyand without limitation. Additionally, the terms and expressions employedherein have been used as terms of description and not of limitation, andthere is no intention in the use of such terms and expressions ofexcluding any equivalents of the future shown and described or anyportion thereof, and it is recognized that various modifications arepossible within the scope of the invention claimed. Thus, it should beunderstood that although the present invention has been specificallydisclosed by preferred embodiments and optional features, modificationand variation of the inventions herein disclosed can be resorted bythose skilled in the art, and that such modifications and variations areconsidered to be within the scope of the inventions disclosed herein.The inventions have been described broadly and generically herein. Eachof the narrower species and subgeneric groupings falling within thescope of the generic disclosure also form part of these inventions. Thisincludes the generic description of each invention with a proviso ornegative limitation removing any subject matter from the genus,regardless of whether or not the excised materials specifically residedtherein.

In addition, where features or aspects of an invention are described interms of the Markush group, those schooled in the art will recognizethat the invention is also thereby described in terms of any individualmember or subgroup of members of the Markush group. It is also to beunderstood that the above description is intended to be illustrative andnot restrictive. Many embodiments will be apparent to those of in theart upon reviewing the above description. The scope of the inventionshould therefore, be determined not with reference to the abovedescription, but should instead be determined with reference to theappended claims, along with the full scope of equivalents to which suchclaims are entitled. The disclosures of all articles and references,including patent publications, are incorporated herein by reference.

What is claimed is:
 1. A method to improve the efficacy and/or reducethe side effects of the administration of a substituted hexitolderivative for treatment of glioblastoma multiforme (GBM) comprising thesteps of: (a) identifying at least one factor or parameter associatedwith the efficacy and/or occurrence of side effects of theadministration of the substituted hexitol derivative for treatment ofGBM; and (b) modifying the factor or parameter to improve the efficacyand/or reduce the side effects of the administration of the substitutedhexitol derivative for treatment of GBM.
 2. The method of claim 1wherein the substituted hexitol derivative is selected from the groupconsisting of galactitols, substituted galacitols, dulcitols, andsubstituted dulcitols.
 3. The method of claim 2 wherein the substitutedhexitol derivative is selected from the group consisting ofdianhydrogalactitol, derivatives of dianhydrogalactitol,diacetyldianhydrogalactitol, derivatives of diacetyldianhydrogalactitol,dibromodulcitol, and derivatives of dibromodulcitol.
 4. The method ofclaim 3 wherein the substituted hexitol derivative isdianhydrogalactitol.
 5. The method of claim 1 wherein the factor orparameter is selected from the group consisting of: (a) dosemodification; (b) route of administration; (c) schedule ofadministration; (d) administration to promote preferential accumulationin brain tissue; (e) selection of disease stage; (f) patient selection;(g) patient/disease phenotype; (h) patient/disease genotype; (i)pre/post-treatment preparation (j) toxicity management; (k)pharmacokinetic/pharmacodynamic monitoring; (l) drug combinations; (m)chemosensitization; (n) chemopotentiation; (o) post-treatment patientmanagement; (p) alternative medicine/therapeutic support; (q) bulk drugproduct improvements; (r) diluent systems; (s) solvent systems; (t)excipients; (u) dosage forms; (v) dosage kits and packaging; (w) drugdelivery systems; (x) drug conjugate forms; (y) compound analogs; (z)prodrugs; (aa) multiple drug systems; (ab) biotherapeutic enhancement;(ac) biotherapeutic resistance modulation; (ad) radiation therapyenhancement; (ae) novel mechanisms of action; (af) selective target cellpopulation therapeutics; (ag) use with ionizing radiation; (ah) use withan agent that counteracts myelosuppression; and (aj) use with an agentthat increases the ability of the substituted hexitol to pass throughthe blood-brain barrier.
 6. The method of claim 5 wherein thesubstituted hexitol derivative is dianhydrogalactitol.
 7. The method ofclaim 5 wherein the improvement is made by dose modification and thedose modification is at least one dose modification selected from thegroup consisting of: (i) continuous i.v. infusion for hours to days;(ii) biweekly administration; (iii) doses greater than 5 mg/m²/day; (iv)progressive escalation of dosing from 1 mg/m²/day based on patienttolerance; (v) use of caffeine to modulate metabolism; (vi) use ofisoniazid to modulate metabolism; (vii) selected and intermittentboosting of dosage administration; (viii) administration of single andmultiple doses escalating from 5 mg/m²/day via bolus; (ix) oral dosagesof below 30 mg/m²; (x) oral dosages of above 130 mg/m²; (xi) oraldosages up to 40 mg/m² for 3 days and then a nadir/recovery period of18-21 days; (xii) dosing at a lower level for an extended period; (xiii)dosing at a higher level; (xiv) dosing with a nadir/recovery periodlonger than 21 days; (xv) dosing at a level to achieve a concentrationof the substituted hexitol derivative in the cerebrospinal fluid (CSF)of equal to or greater than 5 μM; (xvi) dosing at a level to achieve acytotoxic concentration in the CSF; (xvii) the use of the substitutedhexitol derivative as a single cytotoxic agent; (xviii) administrationon a 33-day cycle with a cumulative dose of about 9 mg/m²; (xix)administration on a 33-day cycle with a cumulative dose of about 10mg/m²; (xx) administration on a 33-day cycle with a cumulative dose ofabout 20 mg/m²; (xxi) administration on a 33-day cycle with a cumulativedose of about 40 mg/m²; (xxii) administration on a 33-day cycle with acumulative dose of about 80 mg/m²; (xxiii) administration on a 33-daycycle with a cumulative dose of about 160 mg/m²; (xxiv) administrationon a 33-day cycle with a cumulative dose of about 240 mg/m²; (xxv)administration so that the plasma half-life is about 1-2 hours; (xxvi)administration so that the C_(max) is <200 ng/ml; and (xxvii)administration so that the substituted hexitol derivative has ahalf-life of >20 hours in the cerebrospinal fluid.
 8. The method ofclaim 5 wherein the improvement is made by route of administration andthe route of administration is at least one route of administrationselected from the group consisting of: (i) topical administration; (ii)oral administration; (iii) slow release oral delivery; (iv) intrathecaladministration; (v) intraarterial administration; (vi) continuousinfusion; (vii) intermittent infusion; (viii) intravenousadministration; (ix) administration through a longer infusion; (x)administration through IV push; and (xi) administration to maximize theconcentration of the substituted hexitol derivative in the CSF.
 9. Themethod of claim 8 wherein the route of administration is intravenousadministration and the intravenous administration is intravenousadministration for 30 minutes.
 10. The method of claim 5 wherein theimprovement is made by schedule of administration and the schedule ofadministration is at least one schedule of administration selected fromthe group consisting of: (i) daily administration; (ii) weeklyadministration; (iii) weekly administration for three weeks; (iv)biweekly administration; (v) biweekly administration for three weekswith a 1-2 week rest period; (vi) intermittent boost doseadministration; (vii) daily administration for one week for multipleweeks; and (viii) administration on days 1, 2, and 3 of a 33-day cycle.11. The method of claim 5 wherein the improvement is made by selectionof disease stage and wherein the selection of disease stage is at leastone selection of disease stage selected from the group consisting of:(i) use in an appropriate disease stage for GBM; (ii) use with anangiogenesis inhibitor to prevent or limit metastatic spread; (iii) usefor newly diagnosed GBM; (iv) use for recurrent GBM (v) use forresistant or refractory GBM; and (vi) use for childhood GBM.
 12. Themethod of claim 5 wherein the improvement is made by patient selectionand wherein the patient selection is at least one patient selectioncarried out by a criterion selected from the group consisting of: (i)selecting patients with a disease condition characterized by a highlevel of a metabolic enzyme selected from the group consisting ofhistone deacetylase and ornithine decarboxylase; (ii) selecting patientswith a low or high susceptibility to a condition selected from the groupconsisting of thrombocytopenia and neutropenia; (iii) selecting patientsintolerant of GI toxicities; (iv) selecting patients characterized byover- or under-expression of a gene selected from the group consistingof c-Jun, a GPCR, a signal transduction protein, VEGF, aprostate-specific gene, and a protein kinase. (v) selecting patientscharacterized by carrying extra copies of the EGFR gene for GBM; (vi)selecting patients characterized by mutations in at least one geneselected from the group consisting of TP53, PDGFRA, IDH1, and NF1 forGBM; (vii) selecting patients characterized by methylation or lack ofmethylation of the promoter of the MGMT gene; (viii) selecting patientscharacterized by the existence of an IDH1 mutation; (ix) selectingpatients characterized by the presence of IDH1 wild-type gene; (x)selecting patients characterized by the presence of 1p/19q co-deletion;(xi) selecting patients characterized by the absence of an 1p/19qco-deletion; (xii) selecting patients characterized by an unmethylatedpromoter region of MGMT (O⁶-methylguanine methyltransferase); (xiii)selecting patients characterized by a methylated promoter region ofMGMT; (xiv) selecting patients characterized by a high expression ofMGMT; (xv) selecting patients characterized by a low expression of MGMT;and (xvi) selecting patients characterized by a mutation in EGFR. 13.The method of claim 12 wherein the patient selection is selectingpatients characterized by a mutation in EGFR and the mutation in EGFR isEGFR Variant III.
 14. The method of claim 5 wherein the improvement ismade by analysis of patient or disease phenotype and wherein theanalysis of patient or disease phenotype is a method of analysis ofpatient or disease phenotype carried out by a method selected from thegroup consisting of: (i) use of a diagnostic tool, a diagnostictechnique, a diagnostic kit, or a diagnostic assay to confirm apatient's particular phenotype; (ii) use of a method for measurement ofa marker selected from the group consisting of histone deacetylase,ornithine decarboxylase, VEGF, a protein that is a gene product of jun,and a protein kinase; (iii) surrogate compound dosing; and (iv) low dosepre-testing for enzymatic status.
 15. The method of claim 5 wherein theimprovement is made by analysis of patient or disease genotype and theanalysis of patient or disease genotype is a method of analysis ofpatient or disease genotype carried out by a method selected from thegroup consisting of: (i) use of a diagnostic tool, a diagnostictechnique, a diagnostic kit, or a diagnostic assay to confirm apatient's particular genotype; (ii) use of a gene chip; (iii) use ofgene expression analysis; (iv) use of single nucleotide polymorphism(SNP) analysis; (v) measurement of the level of a metabolite or ametabolic enzyme; (vi) determination of mutation of PDGFRA gene; (vii)determination of mutation of IDH1 gene; (viii) determination of mutationof NF1 gene; (ix) determination of copy number of the EGFR gene; (x)determination of status of methylation of promoter of MGMT gene; (xi)determination of the existence of an IDH1 mutation; (xii) determinationof the existence of IDH1 wild-type; (xiii) determination of theexistence of a 1p/19q co-deletion; (xiv) determination of the absence ofa 1p/19q co-deletion; (xv) determination of the existence of anunmethylated promoter region of the MGMT gene; (xvi) determination ofthe existence of a methylated promoter region of the MGMT gene; (xvii)determination of the existence of high expression of MGMT; and (xviii)determination of the existence of low expression of MGMT.
 16. The methodof claim 15 wherein the method determines a parameter selected from: (i)the copy number of the EGFR gene and (ii) the methylation status of thepromoter of the MGMT gene.
 17. The method of claim 5 wherein theimprovement is made by pre/post treatment preparation and thepre/post-treatment preparation is a method of pre/post treatmentpreparation selected from the group consisting of: (i) the use ofcolchicine or an analog thereof; (ii) the use of a diuretic; (iii) theuse of a uricosuric; (iv) the use of uricase; (v) the non-oral use ofnicotinamide; (vi) the use of a sustained-release form of nicotinamide;(vii) the use of an inhibitor of poly-ADP ribose polymerase; (viii) theuse of caffeine; (ix) the use of leucovorin rescue; (x) infectioncontrol; and (xi) the use of an anti-hypertensive agent.
 18. The methodof claim 5 wherein the improvement is made by toxicity management andthe toxicity management is a method of toxicity management selected fromthe group consisting of: (i) the use of colchicine or an analog thereof;(ii) the use of a diuretic; (iii) the use of a uricosuric; (iv) the useof uricase; (v) the non-oral use of nicotinamide; (vi) the use of asustained-release form of nicotinamide; (vii) the use of an inhibitor ofpoly-ADP ribose polymerase; (viii) the use of caffeine; (ix) the use ofleucovorin rescue; (x) the use of sustained-release allopurinol; (xi)the non-oral use of allopurinol; (xii) the use of bone marrowtransplants; (xiii) the use of a blood cell stimulant; (xiv) the use ofblood or platelet infusions; (xv) the administration of an agentselected from the group consisting of filgrastim, G-CSF, and GM-CSF;(xvi) the application of a pain management technique; (xvii) theadministration of an anti-inflammatory agent; (xviii) the administrationof fluids; (xix) the administration of a corticosteroid; (xx) theadministration of an insulin control medication; (xxi) theadministration of an antipyretic; (xxii) the administration of ananti-nausea treatment; (xxiii) the administration of an anti-diarrhealtreatment; (xxiv) the administration of N-acetylcysteine; and (xxv) theadministration of an antihistamine.
 19. The method of claim 5 whereinthe improvement is made by pharmacokinetic/pharmacodynamic monitoringand the pharmacokinetic/pharmacodynamic monitoring is a method selectedfrom the group consisting of: (i) multiple determinations of bloodplasma levels; and (ii) multiple determinations of at least onemetabolite in blood or urine.
 20. The method of claim 5 wherein theimprovement is made by drug combination and the drug combination is adrug combination selected from the group consisting of: (i) use withtopoisomerase inhibitors; (ii) use with fraudulent nucleosides; (iii)use with fraudulent nucleotides; (iv) use with thymidylate synthetaseinhibitors; (v) use with signal transduction inhibitors; (vi) use withcisplatin or platinum analogs; (vii) use with monofunctional alkylatingagents; (viii) use with bifunctional alkylating agents; (ix) use withalkylating agents that damage DNA at a different place than doesdianhydrogalactitol; (x) use with anti-tubulin agents; (xi) use withantimetabolites; (xii) use with berberine; (xiii) use with apigenin;(xiv) use with amonafide; (xv) use with colchicine or analogs; (xvi) usewith genistein; (xvii) use with etoposide; (xviii) use with cytarabine;(xix) use with camptothecins; (xx) use with vinca alkaloids; (xxi) usewith 5-fluorouracil; (xxii) use with curcumin; (xxiii) use with NF-κBinhibitors; (xxiv) use with rosmarinic acid; (xxv) use with mitoguazone;(xxvi) use with tetrandrine; (xxvii) use with temozolomide; (xxviii) usewith VEGF inhibitors; (xxix) use with cancer vaccines; (xxx) use withEGFR inhibitors; (xxxi) use with tyrosine kinase inhibitors; and (xxxii)use with poly (ADP-ribose) polymerase (PARP) inhibitors.
 21. The methodof claim 20 wherein the drug combination is use with a class of agentselected from the group consisting of: (i) EGFR inhibitors; (ii)tyrosine kinase inhibitors; (iii) PARP inhibitors; and (iv) analkylating agent, wherein the alkylating agent is an alkylating agentselected from the group consisting of BCNU, BCNU wafers (Gliadel), ACNU,CCNU, bendamustine (Treanda), lomustine, and temozolomide (Temodar). 22.The method of claim 20 wherein the drug combination is use with analkylating agent selected from the group consisting of: (a) amonofunctional alkylating agent; (b) a bifunctional alkylating agent;and (c) an alkylating agent that damages DNA at a different place thandianhydrogalactitol.
 23. The method of claim 5 wherein the improvementis made by chemosensitization and the chemosensitization comprises theuse of a substituted hexitol derivative as a chemosensitizer incombination with an agent selected from the group consisting of: (i)topoisomerase inhibitors; (ii) fraudulent nucleosides; (iii) fraudulentnucleotides; (iv) thymidylate synthetase inhibitors; (v) signaltransduction inhibitors; (vi) cisplatin or platinum analogs; (vii)alkylating agents; (viii) anti-tubulin agents; (ix) antimetabolites; (x)berberine; (xi) apigenin; (xii) amonafide; (xiii) colchicine or analogs;(xiv) genistein; (xv) etoposide; (xvi) cytarabine; (xvii) camptothecins;(xviii) vinca alkaloids; (xix) topoisomerase inhibitors; (xx)5-fluorouracil; (xxi) curcumin; (xxii) NF-κB inhibitors; (xxiii)rosmarinic acid; (xxiv) mitoguazone; (xxv) tetrandrine; (xxvi) atyrosine kinase inhibitor; (xxvii) an inhibitor of EGFR; and (xxviii) aninhibitor of PARP.
 24. The method of claim 5 wherein the improvement ismade by chemopotentiation and the chemopotentiation comprises the use ofa substituted hexitol derivative as a chemopotentiator in combinationwith an agent selected from the group consisting of: (i) topoisomeraseinhibitors; (ii) fraudulent nucleosides; (iii) fraudulent nucleotides;(iv) thymidylate synthetase inhibitors; (v) signal transductioninhibitors; (vi) cisplatin or platinum analogs; (vii) alkylating agents;(viii) anti-tubulin agents; (ix) antimetabolites; (x) berberine; (xi)apigenin; (xii) amonafide; (xiii) colchicine or analogs; (xiv)genistein; (xv) etoposide; (xvi) cytarabine; (xvii) camptothecins;(xviii) vinca alkaloids; (xix) 5-fluorouracil; (xx) curcumin; (xxi)NF-κB inhibitors; (xxii) rosmarinic acid; (xxiii) mitoguazone; (xxiv)tetrandrine; (xxv) a tyrosine kinase inhibitor; (xxvi) an inhibitor ofEGFR; and (xxvii) an inhibitor of PARP.
 25. The method of claim 5wherein the improvement is made by post-treatment management and thepost-treatment management is a method selected from the group consistingof: (i) a therapy associated with pain management; (ii) administrationof an anti-emetic; (iii) an anti-nausea therapy; (iv) administration ofan anti-inflammatory agent; (v) administration of an anti-pyretic agent;and (vi) administration of an immune stimulant.
 26. The method of claim5 wherein the improvement is made by a bulk drug product improvement andthe bulk drug product improvement is a bulk drug product improvementselected from the group consisting of: (i) salt formation; (ii)preparation as a homogeneous crystal structure; (iii) preparation as apure isomer; (iv) increased purity; (v) preparation with lower residualsolvent content; and (vi) preparation with lower residual heavy metalcontent.
 27. The method of claim 5 wherein the improvement is made byuse of a diluent and the diluent is selected from the group consistingof: (i) an emulsion; (ii) dimethyl sulfoxide (DMSO); (iii)N-methylformamide (NMF) (iv) DMF; (v) ethanol; (vi) benzyl alcohol;(vii) dextrose-containing water for injection; (viii) Cremophor; (ix)cyclodextrin; and (x) PEG.
 28. The method of claim 5 wherein theimprovement is made by use of a solvent system and the solvent system isselected from the group consisting of: (i) an emulsion; (ii)dimethylsulfoxide (DMSO); (iii) N-methylformamide (NMF) (iv) DMF; (v)ethanol; (vi) benzyl alcohol; (vii) dextrose-containing water forinjection; (viii) Cremophor; (ix) cyclodextrin; and (x) PEG.
 29. Themethod of claim 5 wherein the improvement is made by use of an excipientand the excipient is an excipient selected from the group consisting of:(i) mannitol; (ii) albumin; (iii) EDTA; (iv) sodium bisulfite; (v)benzyl alcohol; (vi) a carbonate buffer; and (g) a phosphate buffer. 30.The method of claim 5 wherein the improvement is made by a dosage formand the dosage form is a dosage form selected from the group consistingof: (i) tablets; (ii) capsules; (iii) topical gels; (iv) topical creams;(v) patches; (vi) suppositories; and (vii) lyophilized dosage fills. 31.The method of claim 5 wherein the improvement is made by use of a drugdelivery system and the drug delivery system is a drug delivery systemselected from the group consisting of: (i) nanocrystals; (ii)bioerodible polymers; (iii) liposomes; (iv) slow release injectablegels; and (v) microspheres.
 32. The method of claim 5 wherein theimprovement is made by use of a drug conjugate form and the drugconjugate form is a drug conjugate form selected from the groupconsisting of: (i) a polymer system; (ii) polylactides; (iii)polyglycolides; (iv) amino acids; (v) peptides; and (vi) multivalentlinkers.
 33. The method of claim 5 wherein the improvement is made byuse of a prodrug system and the prodrug system is selected from thegroup consisting of: (i) the use of enzyme sensitive esters; (ii) theuse of dimers; (iii) the use of Schiff bases; (iv) the use of pyridoxalcomplexes; and (v) the use of caffeine complexes.
 34. The method ofclaim 5 wherein the improvement is made by use of a multiple drug systemand the multiple drug system is selected from the group consisting of:(i) use of multi-drug resistance inhibitors; (ii) use of specific drugresistance inhibitors; (iii) use of specific inhibitors of selectiveenzymes; (iv) use of signal transduction inhibitors; (v) use of repairinhibition; and (vi) use of topoisomerase inhibitors withnon-overlapping side effects.
 35. The method of claim 5 wherein theimprovement is made by biotherapeutic enhancement and the biotherapeuticenhancement is performed by use in combination assensitizers/potentiators with a therapeutic agent or technique that isselected from the group consisting of: (i) cytokines; (ii) lymphokines;(iii) therapeutic antibodies; (iv) antisense therapies; (v) genetherapies; (vi) ribozymes; (vii) RNA interference; and (viii) vaccines.36. The method of claim 5 wherein the improvement is made by use ofbiotherapeutic resistance modulation and the biotherapeutic resistancemodulation is use against glioblastoma multiforme tumors resistant to atherapeutic agent or technique selected from the group consisting of:(i) biological response modifiers; (ii) cytokines; (iii) lymphokines;(iv) therapeutic antibodies; (v) antisense therapies; (vi) genetherapies; (vii) ribozymes; (viii) RNA interference; and (ix) vaccines.37. The method of claim 5 wherein the improvement is made by radiationtherapy enhancement and the radiation therapy enhancement is a radiationtherapy enhancement agent or technique selected from the groupconsisting of: (i) hypoxic cell sensitizers; (ii) radiationsensitizers/protectors; (iii) photosensitizers; (iv) radiation repairinhibitors; (v) thiol depleters; (vi) vaso-targeted agents; (vii) DNArepair inhibitors; (viii) radioactive seeds; (ix) radionuclides; (x)radiolabeled antibodies; and (xi) brachytherapy.
 38. The method of claim5 wherein the improvement is by use of a novel mechanism of action andthe novel mechanism of action is a therapeutic interaction with a targetor mechanism selected from the group consisting of: (i) inhibitors ofpoly-ADP ribose polymerase; (ii) agents that affect vasculature orvasodilation; (iii) oncogenic targeted agents; (iv) signal transductioninhibitors; (v) EGFR inhibition; (vi) protein kinase C inhibition; (vii)phospholipase C downregulation; (viii) Jun downregulation; (ix) histonegenes; (x) VEGF; (xi) ornithine decarboxylase; (xii) ubiquitin C; (xiii)Jun D; (xiv) v-Jun; (xv) GPCRs; (xvi) protein kinase A; (xvii) proteinkinases other than protein kinase A; (xviii) prostate specific genes;(xix) telomerase; (xx) histone deacetylase; and (xxi) tyrosine kinaseinhibitors.
 39. The method of claim 5 wherein the improvement is made byuse of selective target cell population therapeutics and the use ofselective target cell population therapeutics is a use selected from thegroup consisting of: (i) use against radiation sensitive cells; (ii) useagainst radiation resistant cells; and (iii) use against energy depletedcells.
 40. The method of claim 5 wherein the improvement is made by useof a substituted hexitol derivative together with ionizing radiation.41. The method of claim 5 wherein the improvement is made by use of anagent that counteracts myelosuppression.
 42. The method of claim 41wherein the agent that counteracts myelosuppression is adithiocarbamate.
 43. The method of claim 5 wherein the improvement ismade by use with an agent that increases the ability of the substitutedhexitol to pass through the blood-brain barrier.
 44. The method of claim43 wherein the agent that increases the ability of the substitutedhexitol to pass through the blood-brain barrier is selected from thegroup consisting of: (i) a chimeric peptide of the structure of Formula(D-III):

wherein: (A) A is somatostatin, thyrotropin releasing hormone (TRH),vasopressin, alpha interferon, endorphin, muramyl dipeptide or ACTH 4-9analogue; and (B) B is insulin, IGF-I, IGF-II, transferrin, cationized(basic) albumin or prolactin; or a chimeric peptide of the structure ofFormula (D-III) wherein the disulfide conjugating bridge between A and Bis replaced with a bridge of Subformula (D-III(a)):A-NH(CH₂)₂S—S—B (cleavable linkage)  (D-III(a)), wherein the bridge isformed using cysteamine and EDAC as the bridge reagents; or a chimericpeptide of the structure of Formula (D-III) wherein the disulfideconjugating bridge between A and B is replaced with a bridge ofSubformula (D-III(b)):A-NH═CH(CH₂)₃CH═NH—B (non-cleavable linkage)  (D-III(b)), wherein thebridge is formed using glutaraldehyde as the bridge reagent; (ii) acomposition comprising either avidin or an avidin fusion protein bondedto a biotinylated substituted hexitol derivative to form anavidin-biotin-agent complex including therein a protein selected fromthe group consisting of insulin, transferrin, an anti-receptormonoclonal antibody, a cationized protein, and a lectin; (iii) a neutralliposome that is pegylated and incorporates the substituted hexitolderivative, wherein the polyethylene glycol strands are conjugated to atleast one transportable peptide or targeting agent; (iv) a humanizedmurine antibody that binds to the human insulin receptor linked to thesubstituted hexitol derivative through an avidin-biotin linkage; and (v)a fusion protein comprising a first segment and a second segment: thefirst segment comprising a variable region of an antibody thatrecognizes an antigen on the surface of a cell that after binding to thevariable region of the antibody undergoes antibody-receptor-mediatedendocytosis, and, optionally, further comprises at least one domain of aconstant region of an antibody; and the second segment comprising aprotein domain selected from the group consisting of avidin, an avidinmutein, a chemically modified avidin derivative, streptavidin, astreptavidin mutein, and a chemically modified streptavidin derivative,wherein the fusion protein is linked to the substituted hexitol by acovalent link to biotin.
 45. A composition to improve the efficacyand/or reduce the side effects of suboptimally administered drug therapyemploying a substituted hexitol derivative for the treatment of GBMcomprising an alternative selected from the group consisting of: (a) atherapeutically effective quantity of a modified substituted hexitolderivative or a derivative, analog, or prodrug of a substituted hexitolderivative or a modified substituted hexitol derivative, wherein themodified substituted hexitol derivative or the derivative, analog orprodrug of the substituted hexitol derivative or modified substitutedhexitol derivative possesses increased therapeutic efficacy or reducedside effects for treatment of GBM as compared with an unmodifiedsubstituted hexitol derivative; (b) a composition comprising: (i) atherapeutically effective quantity of a substituted hexitol derivative,a modified substituted hexitol derivative, or a derivative, analog, orprodrug of a substituted hexitol derivative or a modified substitutedhexitol derivative; and (ii) at least one additional therapeutic agent,therapeutic agent subject to chemosensitization, therapeutic agentsubject to chemopotentiation, diluent, excipient, solvent system, drugdelivery system, agent to counteract myelosuppression, or agent thatincreases the ability of the substituted hexitol to pass through theblood-brain barrier, wherein the composition possesses increasedtherapeutic efficacy or reduced side effects for treatment of GBM ascompared with an unmodified substituted hexitol derivative; (c) atherapeutically effective quantity of a substituted hexitol derivative,a modified substituted hexitol derivative or a derivative, analog, orprodrug of a substituted hexitol derivative or a modified substitutedhexitol derivative that is incorporated into a dosage form, wherein thesubstituted hexitol derivative, the modified substituted hexitolderivative or the derivative, analog, or prodrug of a substitutedhexitol derivative or a modified substituted hexitol derivativeincorporated into the dosage form possesses increased therapeuticefficacy or reduced side effects for treatment of GBM as compared withan unmodified substituted hexitol derivative; (d) a therapeuticallyeffective quantity of a substituted hexitol derivative, a modifiedsubstituted hexitol derivative or a derivative, analog, or prodrug of asubstituted hexitol derivative or a modified substituted hexitolderivative that is incorporated into a dosage kit and packaging, whereinthe substituted hexitol derivative, the modified substituted hexitolderivative or the derivative, analog, or prodrug of a substitutedhexitol derivative or a modified substituted hexitol derivativeincorporated into the dosage kit and packaging possesses increasedtherapeutic efficacy or reduced side effects for treatment of GBM ascompared with an unmodified substituted hexitol derivative; and (e) atherapeutically effective quantity of a substituted hexitol derivative,a modified substituted hexitol derivative or a derivative, analog, orprodrug of a substituted hexitol derivative or a modified substitutedhexitol derivative that is subjected to a bulk drug product improvement,wherein substituted hexitol derivative, a modified substituted hexitolderivative or a derivative, analog, or prodrug of a substituted hexitolderivative or a modified substituted hexitol derivative subjected to thebulk drug product improvement possesses increased therapeutic efficacyor reduced side effects for treatment of GBM as compared with anunmodified substituted hexitol derivative.
 46. The composition of claim45 wherein the unmodified substituted hexitol derivative is selectedfrom the group consisting of dianhydrogalactitol, derivatives ofdianhydrogalactitol, diacetyldianhydrogalactitol, derivatives ofdiacetyldianhydrogalactitol, dibromodulcitol, and derivatives ofdibromodulcitol.
 47. The composition of claim 46 wherein the unmodifiedsubstituted hexitol derivative is dianhydrogalactitol.
 48. Thecomposition of claim 45 wherein the composition comprises a drugcombination comprising: (a) a substituted hexitol derivative; and (b) anadditional therapeutic agent selected from the group consisting of: (i)topoisomerase inhibitors; (ii) fraudulent nucleosides; (iii) fraudulentnucleotides; (iv) thymidylate synthetase inhibitors; (v) signaltransduction inhibitors; (vi) cisplatin or platinum analogs; (vii)monofunctional alkylating agents; (viii) bifunctional alkylating agents;(ix) alkylating agents that damage DNA at a different place than doesdianhydrogalactitol; (x) anti-tubulin agents; (xi) antimetabolites;(xii) berberine; (xiii) apigenin; (xiv) amonafide; (xv) colchicine oranalogs; (xvi) genistein; (xvii) etoposide; (xviii) cytarabine; (xix)camptothecins; (xx) vinca alkaloids; (xxi) 5-fluorouracil; (xxii)curcumin; (xxiii) NF-κB inhibitors; (xxiv) rosmarinic acid; (xxv)mitoguazone; (xxvi) tetrandrine; (xxvii) temozolomide; (xxviii) VEGFinhibitors; (xxix) cancer vaccines; (xxx) EGFR inhibitors; (xxxi)tyrosine kinase inhibitors; and (xxxii) poly (ADP-ribose) polymerase(PARP) inhibitors.
 49. The composition of claim 45 wherein thecomposition comprises: (a) a substituted hexitol derivative; and (b) atherapeutic agent subject to chemosensitization selected from the groupconsisting of: (i) topoisomerase inhibitors; (ii) fraudulentnucleosides; (iii) fraudulent nucleotides; (iv) thymidylate synthetaseinhibitors; (v) signal transduction inhibitors; (vi) cisplatin orplatinum analogs; (vii) alkylating agents; (viii) anti-tubulin agents;(ix) antimetabolites; (x) berberine; (xi) apigenin; (xii) amonafide;(xiii) colchicine or analogs; (xiv) genistein; (xv) etoposide; (xvi)cytarabine; (xvii) camptothecins; (xviii) vinca alkaloids; (xix)topoisomerase inhibitors; (xx) 5-fluorouracil; (xxi) curcumin; (xxii)NF-κB inhibitors; (xxiii) rosmarinic acid; (xxiv) mitoguazone; (xxv)tetrandrine; (xxvi) a tyrosine kinase inhibitor; (xxvii) an inhibitor ofEGFR; and (xxviii) an inhibitor of PARP; wherein the substituted hexitolderivative acts as a chemosensitizer.
 50. The composition of claim 45wherein the composition comprises: (a) a substituted hexitol derivative;and (b) a therapeutic agent subject to chemopotentiation selected fromthe group consisting of: (i) topoisomerase inhibitors; (ii) fraudulentnucleosides; (iii) fraudulent nucleotides; (iv) thymidylate synthetaseinhibitors; (v) signal transduction inhibitors; (vi) cisplatin orplatinum analogs; (vii) alkylating agents; (viii) anti-tubulin agents;(ix) antimetabolites; (x) berberine; (xi) apigenin; (xii) amonafide;(xiii) colchicine or analogs; (xiv) genistein; (xv) etoposide; (xvi)cytarabine; (xvii) camptothecins; (xviii) vinca alkaloids; (xix)5-fluorouracil; (xx) curcumin; (xxi) NF-κB inhibitors; (xxii) rosmarinicacid; (xxiii) mitoguazone; (xxiv) tetrandrine; (xxv) a tyrosine kinaseinhibitor; (xxvi) an inhibitor of EGFR; and (xxvii) an inhibitor ofPARP; wherein the substituted hexitol derivative acts as achemopotentiator.
 51. The composition of claim 45 wherein thecomposition comprises: (a) a substituted hexitol derivative; and (b) anagent to counteract myelosuppression.
 52. The composition of claim 45wherein the composition comprises: (a) a substituted hexitol derivative;and (b) an agent that increases the ability of the substituted hexitolto pass through the blood-brain barrier.
 53. The composition of claim 45wherein the composition comprises a substituted hexitol derivative and adrug delivery system selected from the group consisting of: (i)nanocrystals; (ii) bioerodible polymers; (iii) liposomes; (iv) slowrelease injectable gels; and (v) microspheres.
 54. The composition ofclaim 45 wherein the substituted hexitol derivative is present in thecomposition in a drug conjugate form selected from the group consistingof: (i) a polymer system; (ii) polylactides; (iii) polyglycolides; (iv)amino acids; (v) peptides; and (vi) multivalent linkers.
 55. Thecomposition of claim 45 wherein the composition comprises a substitutedhexitol derivative and at least one additional therapeutic agent to forma multiple drug system, wherein the at least one additional therapeuticagent is selected from the group consisting of: (i) an inhibitor ofmulti-drug resistance; (ii) a specific drug resistance inhibitor; (iii)a specific inhibitor of a selective enzyme; (iv) a signal transductioninhibitor; (v) an inhibitor of a repair enzyme; and (vi) a topoisomeraseinhibitor with non-overlapping side effects.
 56. A method of treatingglioblastoma multiforme comprising the step of administering atherapeutically effective quantity of a substituted hexitol derivativeto a patient suffering from the malignancy.
 57. The method of claim 56wherein the substituted hexitol derivative is selected from the groupconsisting of galactitols, substituted galacitols, dulcitols, andsubstituted dulcitols.
 58. The method of claim 57 wherein thesubstituted hexitol derivative is selected from the group consisting ofdianhydrogalactitol, derivatives of dianhydrogalactitol,diacetyldianhydrogalactitol, derivatives of diacetyldianhydrogalactitol,dibromodulcitol, and derivatives of dibromodulcitol.
 59. The method ofclaim 58 wherein the substituted hexitol derivative isdianhydrogalactitol.
 60. The method of claim 59 wherein thetherapeutically effective quantity of dianhydrogalactitol is a quantityof dianhydrogalactitol that results in a dosage of from about 1 mg/m² toabout 40 mg/m².
 61. The method of claim 60 wherein the therapeuticallyeffective quantity of dianhydrogalactitol is a quantity ofdianhydrogalactitol that results in a dosage of from about 5 mg/m² toabout 25 mg/m².
 62. The method of claim 59 wherein thedianhydrogalactitol is administered by a route selected from the groupconsisting of intravenous and oral.
 63. The method of claim 59 furthercomprising a step selected from the group consisting of: (a)administering a therapeutically effective dose of ionizing radiation;(b) administering a therapeutically effective quantity of temozolomide;(c) administering a therapeutically effective quantity of bevacizumab;(d) administering a therapeutically effective quantity of acorticosteroid; (e) administering a therapeutically effective quantityof at least one chemotherapeutic agent selected from the groupconsisting of lomustine, cisplatin, carboplatin, vincristine, andcyclophosphamide; (f) administering a therapeutically effective quantityof a tyrosine kinase inhibitor; and (g) administering a therapeuticallyeffective quantity of an EGFR inhibitor.
 64. The method of claim 59wherein the dianhydrogalactitol substantially suppresses the growth ofcancer stem cells (CSCs).
 65. The method of claim 59 wherein thedianhydrogalactitol is effective in suppressing the growth of cancercells possessing O⁶-methylguanine-DNA methyltransferase (MGMT)-drivendrug resistance.
 66. The method of claim 59 wherein thedianhydrogalactitol is effective in suppressing the growth of cancercells resistant to temozolomide.
 67. The method of claim 63 wherein themethod comprises administering a therapeutically effective quantity ofan EGFR inhibitor and wherein the EGFR inhibitor affects wild-typebinding sites.
 68. The method of claim 63 wherein the method comprisesadministering a therapeutically effective quantity of an EGFR inhibitorand wherein the EGFR inhibitor affects mutated binding sites.
 69. Themethod of claim 68 wherein the EGFR inhibitor affects EGFR Variant III.